Flexible children are often celebrated: able to do the splits, impress friends at the gym, or pass themselves off as naturally sporty. What's less visible is that some of these children also have pain that they struggle to explain – joint aches that shift location, fatigue that seems out of proportion to activity, ankles that roll more than they should, and joints that click and pop unprompted.
Joint hypermobility is the most common inherited connective tissue difference, and it exists on a spectrum from completely asymptomatic to significantly disabling. In most children it causes no problems and needs no treatment. In others – particularly those who are more affected and who are going through growth spurts – it is the source of persistent pain that deserves proper recognition and management.
Healthbooq (healthbooq.com/apps/healthbooq-kids) covers paediatric musculoskeletal conditions and childhood health.
Understanding Hypermobility
Connective tissue – ligaments, tendons, and the capsules that surround joints – provides the scaffolding that keeps joints stable. In hypermobility, the connective tissue is more lax than usual, allowing joints to move beyond their typical range. This is primarily a heritable difference in the structure of collagen, the most abundant structural protein in the body.
Hypermobility decreases with age: children are more flexible than adults, and girls are more flexible than boys at the same age. The Beighton score – a 9-point scoring system that assesses flexibility at specific joints (wrists, fingers, elbows, knees, and the spine) – is used clinically to quantify hypermobility, but it is not sufficient on its own for diagnosis because it doesn't capture all affected joints or functional impact.
The current diagnostic framework, revised in 2017 by the International Consortium on EDS, distinguishes between hypermobile Ehlers-Danlos syndrome (hEDS) – which has specific diagnostic criteria including systemic features and family history – and hypermobility spectrum disorders (HSD), a broader category for symptomatic hypermobility that doesn't meet full hEDS criteria. The distinction between hEDS and HSD has less clinical importance than recognising that the child is symptomatic and requires management.
Research by Rodney Grahame at University College London, who spent decades advancing the recognition of hypermobility in UK clinical practice, documented the significant diagnostic delays people with hEDS/HSD experienced – often years of unexplained symptoms before a name was put to the condition. Awareness has improved substantially since the 2017 criteria revision, but delays in paediatric diagnosis remain common.
How Hypermobility Presents in Children
The picture varies considerably by age. In younger children (under 6-7), the most common presentations are late walking, reluctance to walk long distances, and complaints of leg pain after activity that are often labelled growing pains. Many children with symptomatic hypermobility fall more than their peers, have poor balance, or avoid physical activity because it hurts.
In older children and teenagers, the pattern typically includes joint pain that moves around (today the ankles, next week the knees), post-activity pain and stiffness, fatigue that is disproportionate to the level of activity, frequent soft tissue injuries (sprains, strains), and sometimes clicking, popping, or partial dislocations (subluxations) of joints. Headaches are more common in hEDS/HSD than in the general population, possibly related to cervical joint instability. Proprioception – the sense of where a joint is in space – is often reduced, which contributes to both clumsiness and injury risk.
Pain in hypermobility tends to be worst at the end of the day and after physical activity, and is often better in the morning – a pattern that helps distinguish it from inflammatory arthritis, in which morning stiffness is the defining feature. But the two conditions can coexist, and a child with unexplained joint pain should have inflammatory markers (ESR, CRP) checked.
Anxiety and dysautonomia (problems with the autonomic nervous system, including postural tachycardia syndrome) are associated with hEDS/HSD at higher rates than expected by chance. The mechanism is not fully established, but altered connective tissue in vessel walls, the nervous system, and around sensory receptors may contribute. A child with hEDS/HSD who is also experiencing dizziness on standing, rapid heart rate, or significant fatigue should have these features evaluated.
Getting a Diagnosis
There is no blood test or imaging study for hEDS or HSD. The diagnosis is clinical, based on the Beighton score, history of symptoms, examination of all joints, and assessment of systemic features. Many GPs are not familiar enough with the condition to make the diagnosis; paediatric rheumatology, paediatric physiotherapy, or, in specialist centres, connective tissue disease services, are the appropriate referral points.
Parents who suspect hypermobility should bring specific information to the GP: which joints are affected, what activities trigger pain, how long the pain lasts afterwards, whether there is a family history of flexible joints or similar symptoms, and the functional impact – what the child is not doing because of pain or joint instability.
The Hypermobility Syndromes Association (HMSA) provides diagnostic and management resources for families and an online directory of informed clinicians.
What Management Looks Like
There is no treatment that addresses the underlying connective tissue difference. Management is about building the muscular stability that takes over the protective role that lax ligaments are not adequately providing, and about reducing pain and fatigue.
Physiotherapy is the cornerstone. The approach is different from standard physiotherapy for a sports injury: rather than aiming for maximum range of motion (which is counterproductive in hypermobility), the goal is strength, proprioception, and joint control. Core stability work, graduated strengthening of muscles around affected joints, proprioceptive training (balance exercises), and gait retraining where needed are all components. The Hypermobility Physiotherapy Research Group, based at the University of Leeds and led by Jane Simmonds and colleagues, has contributed substantially to the evidence base for physiotherapy-led management.
Pain management may include regular low-dose ibuprofen or paracetamol during flares, but there is no evidence for specific pain medications beyond analgesics. Some children benefit from orthotics (shoe insoles) to support the feet and reduce pain associated with flat arches and excessive pronation. Bracing of specific joints (ankles, knees) can reduce injury risk during sport.
Activity should not be avoided entirely: rest worsens deconditioning and pain in the long term. The goal is paced, graded activity – finding a level that doesn't trigger severe flares and gradually building from there. Swimming and cycling are well tolerated because they don't involve the joint loading of running or jumping. High-impact sports and activities requiring extreme joint loading (gymnastics, competitive dance) are not contraindicated, but the child and parents need to understand the injury risk and manage it with appropriate strength and conditioning.
School adjustments may be needed for children with significant impact on function: rest breaks, avoiding carrying heavy bags, adapted physical education, and, for severe fatigue, reduced school attendance. An EHCP (Education, Health and Care Plan) may be appropriate for those significantly affected.
Key Takeaways
Joint hypermobility – the ability to move joints beyond their normal range – is common in children, with prevalence estimates of 10-30% in school-age children, decreasing with age. Most hypermobile children are asymptomatic. When hypermobility causes pain, fatigue, instability, and functional limitation, the diagnosis is hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD). These conditions are frequently underrecognised, particularly in children whose pain is attributed to growing pains or attention-seeking. Management centres on physiotherapy to build joint stability and strength; there is no curative treatment.
