Hypermobility in the Pediatric Population

Editor's note: This text-based course is a transcript of the webinar, Hypermobility in the Pediatric Population, presented by Jesse Miller, MS, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Identify the nine points of the Beighton Scale.
• List three or more co-morbidities that may accompany joint hypermobility.
• Describe three treatment techniques to implement with patients presenting with joint hypermobility.

Introduction

Thank you all for being here. I am really excited to talk about hypermobility in the pediatric population today. This is a passion of mine, and I have a special place in my heart for this topic, so I can't wait to share it with you.

Before we dig in, I want to touch briefly on a few housekeeping items. Any information I'm sharing that is specific to Ehlers-Danlos syndrome was used with written permission, and you're welcome to visit the Ehlers-Danlos Society's website to explore the resources I'll reference throughout the slides. I did receive an honorarium for today's presentation, but I have no other relevant financial or non-financial relationships to disclose. I'd also encourage you to read through the limitations and risks in your handout at your own pace, since we're going to spend most of our time together on the clinical content.

So, what are we building toward today? By the end of this course, I want you to be able to identify the nine points of the Beighton Scale, which is the tool we use to help diagnose patients with hypermobility. I also want you to be able to list 3 or more comorbidities that can accompany joint hypermobility from a connective tissue standpoint, and to describe 3 treatment techniques you can use with patients who present with joint hypermobility.

We're talking about the pediatric population today, which I'm defining as infancy through 18 years of age. A lot of what we cover will bleed into adulthood as well, so some of the foundational information applies broadly, but our treatment focus is going to stay rooted in how hypermobility shows up and is supported across childhood and adolescence.

We'll walk through the differential diagnoses, the different types of hypermobility you might encounter, and what distinguishes one from another. We'll talk about the anatomical considerations and how to use the Beighton Scale, which is the tool currently used to diagnose specific types of joint hypermobility. Throughout, my biggest goal is to build your awareness of the co-morbidities and underlying conditions associated with joint hypermobility, so that you can support this population as they move through childhood and into adulthood.

What Causes Joint Hypermobility?

Let's start with the basics. The exact cause of joint hypermobility isn't fully known, but it falls under the broader umbrella of connective tissue disorders. Connective tissue disorders are genetic conditions involving various gene mutations that cause connective tissue to be either more lax or, in some cases, more rigid than typical.

There are many different types of connective tissue in the body, and each contributes to different presentations. Today, we're going to focus specifically on what happens when there's a defect in the production or preservation of collagen. Collagen is critically important in the body. It provides structure and strength to nearly every part of us. From a joint hypermobility standpoint, we see this most clearly in the ligaments and tendons that surround our joints, but connective tissue doesn't stop there. It's in our organs, our blood vessels, our nervous system. It's woven into every system of the body.

This is why, once we start talking about co-morbidities, you'll begin to see the bigger picture. Yes, we have joint hypermobility that shows up in a localized area. But we also have a spectrum where that same connective tissue vulnerability can affect multiple systems throughout the body. This is really important for us to recognize as occupational therapy practitioners, because we have such close, hands-on interaction with our patients. We get to see these things up close during our treatment sessions in a way that other providers, who may only see a child for a fifteen-minute well visit, simply don't.

Why Is It Important to Recognize Joint Hypermobility?

We are often the first people to notice these small, easy-to-miss signs. The more we know, and the more familiar we become with the other symptoms and connective tissue-related presentations that might be showing up alongside hypermobility, the more likely we are to be the ones who start connecting the dots for a family. Joint hypermobility may be the very first sign of a genetic condition. That's not always the case; there are plenty of people who simply have localized joint hypermobility and nothing more. But we can be a valuable member of the care team, helping patients get connected to the support they need.

Heritable Disorders of Connective Tissue (HDCT) are a group of rare genetic disorders that can present with joint hypermobility. This category includes Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, and Loeys-Dietz syndrome, among others. I say "rare," but that rarity is shifting. We're getting more research on each of these diagnoses, and the more we learn, the more we're able to recognize them in our patients.

Because of this, many patients have historically been misdiagnosed or undiagnosed. Right now, the average time to diagnosis within this spectrum of connective tissue disorders is ten to twenty years. My passion is figuring out how we can educate pediatric therapists to notice the little things early — not necessarily to diagnose, but to be on the forefront of recognizing patterns so we can support these patients as they move through the lifespan.

Four Types of Joint Hypermobility

Today, we're going to focus on four types of joint hypermobility: localized joint hypermobility, generalized joint hypermobility, hypermobility spectrum disorder, and hypermobile Ehlers-Danlos syndrome. There are other heritable connective tissue disorders beyond these; some are even rarer than the ones I've listed, but these four categories are the ones I most consistently see in clinical practice, and they're a great foundation for building your clinical reasoning.

Localized Joint Hypermobility (LJH)

Localized joint hypermobility typically affects one or fewer joints throughout the body. Picture a child who plays baseball or T-ball and comes in with elbow pain from elbow hypermobility. That could be a purely localized presentation or the symptom they're experiencing in the clinic. In fact, many of these patients are entirely asymptomatic. You may never see them in your clinic at all because they aren't bothered by the hypermobility. Or you might see them for joint pain in a specific area, with no other joints involved and no systemic symptoms layered on top.

I find it helpful to picture a young athlete who is otherwise completely healthy and active. Maybe they've never had a single complaint about their body until the day they show up with elbow soreness after a season of pitching or batting. When you assess them and find hyperextension isolated to that one joint, with no other joints involved, no reported fatigue, no gastrointestinal complaints, and no family history suggesting a broader connective tissue picture, that clinical picture points toward localized joint hypermobility rather than something more systemic. This distinction matters because it changes both the conversation you have with the family and the plan of care you build; this child likely needs joint-protection strategies and load management for that one joint, rather than a broader referral network.

This presentation is sometimes casually referred to as being "double-jointed," and it's not typically associated with other diagnoses. That said, these joints may be more prone to injury. Any joint that's unstable is already at increased risk in a pediatric population whose bones, ligaments, and joint structures aren't yet fully developed. Add localized joint instability on top of that developmental vulnerability, and these children may be somewhat more prone to injury when those specific joints are put under load or stress.

Generalized Joint Hypermobility (GJH)

Generalized joint hypermobility is one of the more common presentations you'll encounter in the pediatric population. This term describes joints that move beyond the typical range of motion for that person's age; remember, the typical range of motion varies by age group. With GJH, we typically see this excess mobility present in five or more joints throughout the body.

Many of these patients may or may not experience pain. When pain is present, it's often inconsistent or tied to a specific injury, since these joints are more prone to injury when they're hypermobile. Generally speaking, though, the symptoms in generalized joint hypermobility tend to stay contained to joint pain and joint limitations. We're not necessarily seeing this spread into other connective tissue-related systems throughout the body. You can use the Beighton Scale to assess for generalized joint hypermobility by scoring nine specific body points, but a patient in this category typically won't report the additional systemic complaints we'll discuss shortly.

Hypermobility Spectrum Disorder (HSD)

Hypermobility spectrum disorder refers to patients with symptomatic joint hypermobility. They're coming in with complaints across multiple joints: pain, soreness, fatigue. These patients often struggle more with tolerance, with healing, and with repetitive strain or repetitive injury. Importantly, they don't fit the diagnostic criteria for other connective tissue disorders.

We still use the Beighton Scale here to determine where and to what extent joint hypermobility is present. But we're also looking at how well other systems of the body tolerate this underlying connective tissue difference, because that same laxity, that same challenge in generating tensile strength, can show up in other systems too. This might come out as gastrointestinal issues, headaches, or dizziness, all of which we'll cover in more detail shortly.

This is where, as occupational therapy practitioners, we can start to get curious. If we're treating a child who has been identified with generalized joint hypermobility but who is also symptomatic across multiple joints, it's worth asking a few more questions. Are there any other symptoms going on? Any challenges going to the bathroom? Any difficulty sitting upright at a desk for long periods at school? Were they late to walk? Do they struggle with handwriting? As we start piecing this picture together, we move further along the spectrum toward hypermobility spectrum disorder, and with that comes more opportunities for us as occupational therapy practitioners (OTPs) to intervene meaningfully.

Hypermobile Ehlers-Danlos Syndrome (hEDS)

At the far end of this spectrum sits hypermobile Ehlers-Danlos syndrome, or hEDS. Overall, Ehlers-Danlos syndrome is a connective tissue disorder that makes it more challenging for the body to maintain connective tissue stability, and it has 13 recognized subtypes. Today, we're focusing specifically on the hypermobile subtype, since it's most relevant to our topic, but I want you to know that this is a genetic, heritable connective tissue disorder across all its variations.

In hEDS, we typically see consistent joint dislocations, subluxations, and joint laxity, along with ongoing complaints of joint or muscle pain. Sometimes there's skin involvement as well — lax or stretchy skin. And critically, we start to see other body systems become involved, which is part of what distinguishes hEDS from the categories we've already discussed.

There is a specific diagnostic criterion used to formally diagnose hEDS. If we suspect a patient may be moving in this direction, say, they have five or more hypermobile joints, they're symptomatic, and they're also reporting gastrointestinal issues or challenges with handwriting and endurance, we start to consider this possibility. In a very young child who isn't yet in school, some of these symptoms may not be fully evident yet. But we often see these symptoms emerge more clearly during school age, when children are required to sit upright at a desk, concentrate, and use multiple body systems throughout the day, all while feeling unstable and unsupported in their own bodies.

As of 2017, there is an established diagnostic criterion for hEDS, developed with input from the International Consortium on Ehlers-Danlos Syndromes and Related Disorders. However, I want to flag something important: new diagnostic guidelines distinguishing between hypermobility spectrum disorder and hEDS are expected to be released in December of 2026 and into early 2027. There is a great deal of active research happening in this space right now. I've been working with this population since 2015, attending the Global Learning EDS Conference every year as a hand therapist, and the amount of new information that has come out since 2017 has been remarkable. I expect we'll see even more clarity and refined guidelines in the coming months.

At the end of the day, our job as OTPs is to help our patients live successfully in their bodies — to function well, to feel capable, and to find agency and belief in the symptoms they're experiencing. That work starts in pediatrics and in adolescence. The diagnostic criteria I'm sharing with you today can be used now. If you want to go deeper on this topic, I'd recommend a course called Taming the Zebra with Stephanie Purdon, a physical therapist who specializes in this diagnostic space. There's a wealth of information available if you want to build further expertise here.

The 2017 Diagnostic Criteria for Hypermobile EDS

I want to walk you through the current diagnostic criteria in a bit more detail, because it can feel dense the first time you encounter it, and I think it's worth demystifying. A clinical diagnosis of hEDS requires the simultaneous presence of all three criteria.

Criterion 1 is generalized joint hypermobility, established using the Beighton Scale with the age-adjusted cutoffs I described earlier. If a patient's Beighton score falls just one point below their age-specific cutoff, the criteria allow for two additional questions to still meet this criterion: Can you now, or could you ever, place your hands flat on the floor without bending your knees? Can you now, or could you ever, bend your thumb to touch your forearm? Have you ever been able to contort your body into strange shapes or do the splits? As a child or teenager, did your shoulder or kneecap ever dislocate on more than one occasion? Do you consider yourself "double-jointed"? Two or more "yes" answers here can still satisfy Criterion 1 even with a borderline Beighton score.

Criterion 2 requires two or more of the three feature categories to be present. Feature A includes things like unusually soft or velvety skin, mild skin hyperextensibility, unexplained stretch marks, small bumps over pressure points like the heels, recurrent abdominal hernias, atrophic scarring, pelvic or rectal prolapse, dental crowding with a high or narrow palate, long slender fingers, an arm span greater than height, mild heart valve involvement, or mild aortic root widening — at least five of these must be present to count Feature A. Feature B is simply a positive family history, with a first-degree relative who also meets hEDS criteria. Feature C requires at least one of the following: musculoskeletal pain in two or more limbs occurring daily for at least three months, widespread chronic pain lasting three months or more, or recurrent joint dislocations or frank instability without a history of trauma.

Criterion 3 requires that all of the following be true: there is an absence of unusual skin fragility, which would otherwise point toward a different EDS subtype; other heritable and acquired connective tissue disorders have been ruled out, including autoimmune rheumatologic conditions; and alternative diagnoses that can also present with joint hypermobility,  including neuromuscular disorders, other connective tissue conditions like Loeys-Dietz or Marfan syndrome, and skeletal dysplasias such as osteogenesis imperfecta, have been excluded through history, physical examination, and molecular genetic testing where appropriate.

I share this level of detail not because occupational therapists are the ones making this diagnosis, but because understanding the full picture helps us recognize when a referral to a geneticist or rheumatologist is warranted, and it helps us have more informed conversations with the families we're supporting.

The Other Subtypes of Ehlers-Danlos Syndrome

For context, I want you to be familiar with the other twelve subtypes of EDS beyond the hypermobile type. These include classical EDS, vascular EDS, classical-like EDS, arthrochalasia EDS, brittle cornea syndrome, cardiac-valvular EDS, dermatosparaxis EDS, kyphoscoliotic EDS, musculocontractural EDS, myopathic EDS, periodontal EDS, and spondylodysplastic EDS. Hypermobile EDS, classical EDS, and vascular EDS are considered the most common subtypes, while the others are rarer. That doesn't mean you'll never encounter them clinically; depending on your practice setting, you may also encounter patients with these other subtypes. And because all of these conditions fall under the connective tissue disorder umbrella, each has the potential for joint hypermobility, not just the hypermobile subtype.

Why Getting the Category Right Matters

I want to pause to consider why it's worth taking the time to carefully differentiate among these four categories, rather than simply labeling every hypermobile child the same way. Each category carries a different plan of care, a different urgency around referral, and a different conversation with the family. A child with purely localized joint hypermobility in one elbow needs joint protection education and load management, full stop. A child with generalized joint hypermobility across five or more joints, but no other symptoms, benefits from postural and proprioceptive support, but doesn't necessarily need an urgent referral to genetics or rheumatology. A child who is symptomatic across multiple joints and multiple systems, meeting criteria for hypermobility spectrum disorder, benefits from a broader care team and closer monitoring over time. And a child who may be trending toward hEDS deserves a more formal diagnostic workup, because that diagnosis often unlocks access to specialists, school accommodations, and a more coordinated, systemic plan of care.

Getting this distinction right isn't about assigning a label for the sake of paperwork. It's about making sure each child receives the right intensity and breadth of support, no more and no less, and about making sure we aren't either over-medicalizing a child who simply has flexible joints, or under-supporting a child whose body is quietly struggling across multiple systems.

Discerning Between the Categories

So, how do we tell the difference between localized and generalized presentations, and between HSD and hEDS, from a broad, practical standpoint? A few clinical questions can help guide your thinking.

Ask about fatigue and exhaustion. When joint hypermobility is coupled with significant fatigue and exhaustion, it leans more toward the hypermobility spectrum disorder and hEDS end of things. We see this less commonly in localized or generalized joint hypermobility alone. These patients often need more rest after activity. They may not have the same endurance as their peers, may need more frequent breaks, and may not be able to participate in activities the same way other children can.

Also, pay attention to gravitational effects on the body. This shows up especially in postural changes, and I think we're seeing this become more pronounced in a generation of children who spend a lot of time on cell phones, iPads, and school computers. Children in the HSD and hEDS spectrum tend to show more severe gravitational effects than children with generalized joint hypermobility alone, lower endurance for postural stability, and for staying upright against gravity over time. Interestingly, we can sometimes see early signs of this even in infancy, in the form of difficulty maintaining a position for a prolonged period. It doesn't always correlate directly, but it's worth staying curious about as a child progresses through their developmental stages.

Finally, patients in the HSD and hEDS spectrum tend to be more hypersensitive and more bothered by minor injuries, more sensitive, generally, to things happening in and around their bodies. And as I mentioned, we'll often see co-occurring conditions showing up at the same time, because those systems are also supported by the same connective tissue. Sometimes we are the first people to help a family connect these pieces.

The Beighton Scale

The Beighton Scale is the clinical assessment tool we currently use to evaluate general joint hypermobility. It was developed by Professor Peter Beighton in 1973, and while it has been in consistent use for decades, there is a strong push right now to refine the research and diagnostic criteria so we can better support patients from a young age and recognize hypermobility earlier across the lifespan.

The scale evaluates five specific areas of the body: the fifth digit (pinky finger), the thumb, the elbow, the knee, and the spine. I want to acknowledge upfront that this isn't every joint in the body, and that is one of the scale's real limitations. A child with hip hypermobility, hip dislocations, shoulder hypermobility, shoulder dislocations, or cervical spine involvement may be missed entirely by this scale, even though their joints are genuinely unstable. So while this remains our primary diagnostic tool, it's worth remembering its blind spots as you evaluate your patients clinically.

The Beighton Scale is typically used starting around age 2, and the diagnostic threshold changes across the lifespan. Children before puberty need to score at least 6 out of 9 possible points to be considered positive for generalized hypermobility. From puberty through age 50, the threshold drops to 5 out of 9. And for adults over 50, the threshold drops further to 4 out of 9. This tells us something important: hypermobility tends to be more prevalent in younger bodies and less prevalent as we age, though that trajectory can look different for each patient depending on how their joints have been preserved and managed across their lifetime.

Here's how the nine points break down:

• Fifth finger (pinkies). With the palm and forearm resting flat on a surface, fingers straight, can the fifth finger be lifted or bent backward at the knuckle beyond 90 degrees? If yes, that's one point for each hand, up to two points total.
• Thumbs. With the arm extended, palm facing down, and the wrist fully flexed downward, can the thumb be pushed back to touch the forearm? If yes, that's one point for each thumb, bringing the running total to four points if both fingers and thumbs test positive.
• Elbows. With the arms outstretched and palms facing upward, does the elbow hyperextend more than 10 degrees beyond a normal outstretched position? I want to emphasize the use of a goniometer here because some elbow hyperextension is entirely normal; some people naturally sit around 5 degrees. We're specifically looking for that 10-degree-or-greater threshold, which signals a more unstable joint position. One point for each side, adding up to six points if all prior criteria were also positive.
• Knees. While standing, with the knees locked and bent backward as far as possible, does the lower leg extend more than 10 degrees forward? Again, one point for each side.
• Spine. Bending forward with the knees fully extended, can the patient place their palms flat on the floor in front of their feet? If yes, that's one additional point, bringing the total possible score to nine.

Remember: children before puberty need six or more of these nine points to be considered positive for generalized joint hypermobility, and that threshold drops to five for those from puberty through age 50.

Common Co-Morbidities

As we move further along the spectrum from HSD into hEDS, we start to see more body systems become involved. This is where the co-morbidities come in, and I want to walk you through several that I most commonly see in the pediatric and young adult population: postural orthostatic tachycardia syndrome, mast cell activation syndrome, gastrointestinal issues, pelvic health and bowel and bladder issues, and neurodiversity. It can be difficult to imagine all of these showing up in a child, but I promise you, they do, and recognizing them early makes a real difference in the support we can offer.

Postural Orthostatic Tachycardia Syndrome (POTS)

POTS is a condition that affects the body's ability to regulate the autonomic nervous system. It shows up alongside hypermobility because both are connective tissue disorders, and connective tissue is found throughout the arterial system. The primary symptoms include dizziness and lightheadedness — especially with position changes — fainting or a feeling of impending fainting, exercise intolerance, easy fatigue with difficulty recovering from movement, and heart palpitations.

If a parent tells you their child gets dizzy at recess, or a gym teacher reports that a student doesn't have enough energy to stay upright, or a child is frequently resting their head on their desk, these are the kinds of details worth getting curious about. As occupational therapists, we can support these patients by recommending compression or supportive garments, helping to build predictable routines, and teaching breathing techniques that promote autonomic regulation.

I want to underscore why this particular co-morbidity shows up so often alongside hypermobility. Both conditions trace back to connective tissue, which is a major structural component of the arterial system itself. When that tissue is more lax than typical, the vascular system doesn't constrict and adjust as efficiently as it does when a child changes position — say, moving from lying down to standing up quickly. That's what drives the dizziness, the lightheadedness, and the palpitations. Once you understand that mechanism, POTS stops feeling like an unrelated, surprising diagnosis to uncover in a hypermobile patient, and starts feeling like a natural extension of the same underlying connective tissue picture.

Mast Cell Activation Syndrome (MCAS)

Mast cells are a type of specialized white blood cell that play a vital role in the body's immune system, and they're completely normal and necessary. MCAS occurs when these mast cells become too active. Because mast cells live within connective tissue, which is everywhere in the body, the resulting inflammatory changes can affect multiple organ systems in ways that may initially feel unrelated to hypermobility.

There are countless possible symptoms with MCAS, but some of the more common ones include hives and rashes, rapid heart rate, and gastrointestinal symptoms like nausea, bloating, diarrhea, and reflux. As OTPs, we can help by discussing how to track potential triggers and adapt the environment to prevent flare-ups. This might mean recommending school modifications, such as reduced lighting or scent-free spaces, and supporting families in building predictable daily schedules.

Gastrointestinal Issues

GI issues frequently occur with hypermobility because connective tissue lines and supports the entire GI tract. Symptoms can include delayed gastric emptying or dysmotility, heartburn and reflux, constipation and bloating, and extreme fullness after meals, sometimes even meals that seem small. As practitioners, teaching age-appropriate breathing techniques and educating parents or caregivers on gentle abdominal massage can help. When GI symptoms are more significant, referring out to other professionals, such as a pediatric gastroenterologist, is an important part of comprehensive care.

If you work in a setting like an outpatient orthopedic clinic, where GI concerns fall outside your typical scope of practice, I still encourage you to listen closely when parents mention these details during a session. Parents talk, and children talk, and sometimes a passing comment about tummy troubles or trouble finishing a meal is the piece of information that helps you build a more complete referral network around that child. You don't need to become a GI specialist yourself; you simply need to stay curious enough to connect that family with someone who is.

Pelvic Health, Bowel, and Bladder Issues

Connective tissue is also found extensively in the pelvic region, and these conditions are often compounded by poor postural awareness, which places additional load on the pelvic floor. Symptoms can include an overactive bladder, urinary or fecal incontinence, recurring urinary tract infections, and constipation. The most valuable thing we can do here, as OTPs, is to refer to a pelvic health occupational or physical therapist who specializes in this area. Even when this falls outside your own direct scope, recognizing the pattern and making that referral promptly can spare a family years of unnecessary frustration, especially since bowel and bladder concerns are often the symptoms families feel most uncomfortable bringing up on their own.

Neurodiversity

Neurodiversity encompasses a group of neurodevelopmental conditions, including ADHD, autism, and Tourette syndrome. Research shows that neurodivergent populations demonstrate an elevated prevalence of hypermobility, around 51%, compared to roughly 20% in the general population and 17.5% in comparison populations. As OTPs, we can help these patients by teaching them to recognize when their joints are in hypermobile positions and explaining why staying within "safe movement" patterns matters. It's also worth identifying whether a child has a desire to pop or crack their joints, and discussing how fidget toys or splints might help support joint stability while still meeting that sensory-seeking need.

I want to be clear: as therapists, we are not diagnosing these conditions. But building this broader lens allows us to get curious about how these pieces may fit together, and to determine what we can offer our patients to support whatever manifestations may be showing up.

Musculoskeletal and Additional Symptoms to Watch For

From a musculoskeletal standpoint, hypermobility can present with motor delays and motor control deficits; clumsiness or frequent bruising; frequent sprains, dislocations, or subluxations; and joint or muscle pain with other soft-tissue involvement. I want to spend a moment on subluxations specifically, because they don't always look dramatic. Sometimes it's not the kind of subluxation we picture, where a bone is fully out of place. It might be a bone that is only slightly displaced, with a body that lacks the collagen structure to correct it, leaving it in that mildly displaced position for a prolonged period and resulting in joint pain with no obvious cause, no big traumatic event that explains why the knee, foot, or hand suddenly hurts. That subtle subluxation might not even register to the child as an event, but the underlying laxity opens the door to these smaller, quieter injuries.

Additional symptoms to watch for include bowel and bladder dysfunction, dizziness or fainting, and muscle stiffness. When these symptoms begin to appear alongside joint hypermobility, our clinical thinking should shift more toward hypermobility spectrum disorder and less toward localized or generalized joint hypermobility alone.

I also want to highlight neurosensitivity as a symptom category worth watching. There appears to be a meaningful correlation between neurosensitivity and hypermobility across this spectrum, and we'll circle back to that connection when we discuss neurodiversity as a comorbidity. In practice, this might look like a child who seems disproportionately bothered by certain textures, sounds, or types of touch, layered on top of the joint symptoms we've already discussed. None of these symptoms exists in isolation from the others. They tend to occur together because they all trace back to the same underlying vulnerability in connective tissue.

What Is "Normal" Range of Motion?

It's worth pausing here to talk about what "normal" range of motion actually means. The normal range of motion was established using normative values from large-scale clinical studies, in which researchers measured joint angles in healthy individuals and used the data to define a standard. These norms vary by age, and the CDC recognizes categories including 2 to 8 years old, 9 to 19 years old, 20 to 44 years old, and 45 to 69 years old. Broadly speaking, we tend to see greater mobility in younger bodies than in older ones, so some increase in range of motion in children is entirely typical. It's when we start to see symptomatic presentations layered on top of that mobility that our concern increases.

How OT Can Help with Hypermobility in Pediatrics

Before we walk through each age range individually, I want to name the broad categories of support that occupational therapy practitioners can offer across this entire population. We can support proprioceptive feedback, postural awareness, sensory integration, handwriting, and breath work. That's a wide net, and it should be, because hypermobility rarely shows up as a single, isolated concern. It touches a child's participation across nearly every area of their day: how they sit at their desk, how they hold a pencil, how they tolerate a full day of school, and how they recover once they get home.

I know that, broadly speaking, OTPs are primarily associated with handwriting in this age group, and that is certainly a meaningful part of the work. But I want to stretch your thinking beyond that. There is so much more we can offer this population: helping a child build genuine postural endurance, teaching a teenager to advocate for their own body, or helping a toddler's nervous system, for the first time, understand what true joint stability actually feels like. Let's break this down further by age group.

Presentation of Hypermobility Across the Age Ranges

Let's walk through how hypermobility tends to present at different developmental stages, along with assessment ideas and treatment strategies for each age group. I want to be honest with you: if hypermobility isn't recognized at an earlier stage, it will typically progress to the next stage. That's exactly why early recognition matters so much.

Infancy: Birth to 12 Months

In infancy, we may not yet see dramatic hypermobility, and that's expected. Infants naturally have some baseline ligamentous laxity as their bodies learn to bear weight against gravity for the first time. Historically, what we're now recognizing as early hypermobility in infants has been labeled "floppy baby syndrome," low or poor tone, or delayed motor development. We now understand these presentations may fall on the spectrum of hypermobility and joint instability, even this early in life.

Watch for avoidance of tummy time and for delayed motor milestones, such as delayed sitting, crawling, or pulling to stand. I want to emphasize that a single delayed milestone doesn't automatically mean hypermobility. Every baby develops at their own pace. But when I see multiple delays, more delayed than I would typically expect, and delays occurring together rather than in isolation, that's when I start paying closer attention.

For assessment, I like to observe the baby in a prone position and watch for any desire to move out of it or to avoid it altogether. I also observe them in weight-bearing positions, which can vary from month to month, and I note any "locking out" or hyperextension of the joints, which is often seen during standing activities. I also look for positions of consistent avoidance and observe the baby's preferred grip patterns. None of these observations is inherently bad or wrong on its own, but they're simply information that helps build a fuller picture of what this infant's body is doing and how it's finding, or struggling to find, stability.

I also pay close attention to grip patterns in infants, even at this very early stage. This doesn't mean I'm assigning a diagnosis to a seven-month-old based on how they hold an object; I'm just gathering information. If I notice a baby consistently wrapping their fingers in a way that hyperextends the interphalangeal joint, or if I see them favoring one grip pattern without ever varying it, I'll offer a gentle cue, guiding their hand toward a more rounded, C-shaped grasp around an object. I'm not trying to force a change; I'm offering their nervous system another option and watching whether they adapt to it or return to their habitual pattern. The same logic applies to standing: if I see knees locking into hyperextension, I'm comfortable with that as one pattern, but I'll also have the child practice standing with the knees in slight flexion, so their body has access to both patterns rather than defaulting to only one.

For treatment, my first priority is making tummy time fun. I start with short time frames and build tolerance gradually, grading the required effort by varying the surface or position, using a parent's or caregiver's chest, a stability ball for visual and spatial feedback, or a wedge or pillow to create a gravity-modified version of prone positioning. In weight-bearing positions, I provide support to help the baby rock forward onto their palms and back onto their knees, which builds mid-body awareness and engagement. I also incorporate activities that allow for slight bending at the joints, particularly the knees and ankles, which help prevent toe-walking patterns later on, along with sensory stimulation to the bottoms of the feet to build awareness of weight-bearing. Gentle joint compressions at the hips, knees, and ankles can also provide helpful proprioceptive feedback, essentially teaching the nervous system, "here is your hip, here is your knee, here is your ankle," and building that early neural connection to the body's own joints.

Toddlers: Ages 1 to 4

In toddlerhood, we tend to see more pronounced challenges with postural control. Watch for "W" sitting, being late to walk, jump, or run, toe-walking, and poor endurance. Children who fatigue easily and report joint pain, especially in the ankles and feet. You'll also see visibly flexible joints: children who can easily hyperextend their fingers, elbows, and knees, which the Beighton Scale can help quantify.

A pattern I commonly see in this age group is a particular weight-bearing habit at the hands, where a child leans into hyperextension at the thumb's MCP joint, which I call a "pitched" position, sending all of that load into the tiny CMC joint at the base of the thumb. This is where we want to redirect toward a flat-palm weight-bearing pattern, which distributes pressure more evenly up through the arm and gives the child much richer sensory feedback into the fingers and hand. We're essentially training midline activation for stability, rather than allowing the body to stabilize through those distal joints.

For assessment, observe sitting and standing positions with attention to joint positioning, observe grip patterns across a range of object sizes, and watch the child in weight-bearing positions such as hands and knees, wheelbarrow walking, or the cobra position, noting whether they consistently avoid certain positions.

Treatment at this age is overwhelmingly about parent and caregiver education. This is the most important piece for this age group: teaching parents how to support their child without feeling pressure to correct everything, and creating opportunities for the whole family to learn together. I like to incorporate weight-bearing directly into play;  think "act out the animal" games, or pushing and pulling heavy objects with attention to hand positioning. I also encourage reducing "W" sitting in favor of a cross-legged "criss-cross applesauce" position, which can be built into floor play naturally by placing an activity in front of the child and having them bear weight through one hand while reaching with the other.

One thing I always keep in mind at this age is that toddlers already have a lot being asked of them developmentally, so I try not to overload parents with too many corrections at once. A single, simple cue, repeated consistently, tends to go much further than a long list of adjustments. If I see a toddler up on a hyperextended thumb during floor play, I'll simply say, "Let's put your whole hand flat," and let that repetition do the work over time rather than trying to address every joint at once.

I also teach parents and caregivers simple, easy cues for supporting joint stability. For example, encouraging a flat-hand weight-bearing pattern instead of balancing on hyperextended thumbs or MCP joints. Gentle proprioceptive input through joint compression at proximal joints, such as the hips and shoulders, can help build spatial awareness. And sensory stimulation to the hands and feet, through water mat play, putty play with an emphasis on weight-bearing through the palm, or texture training with materials like sand, rice, or beans, supports both sensory awareness and functional weight-bearing patterns simultaneously.

Young School Age: 5 to 12

If hypermobility isn't recognized in earlier years, it typically continues to progress into this age range, and we start to see it become more visible. Watch for muscle and joint pain, sprains, and strains that are often mistaken for growing pains, difficulty sitting for long periods, fidgeting, poor handwriting endurance, non-traditional pencil grip patterns, and fatigue or exhaustion, especially after a full school day.

Assessment at this age looks fairly similar to what we've already discussed, with an added focus on school-related demands. Continue using the Beighton Scale to formally assess hypermobility, and observe handwriting, as well as grip and pinch positions. Observe posture in seated, standing, and quadruped positions, and discuss the child's endurance for schoolwork and extracurricular activities. It's also worth being alert to the potential development of anxiety related to pressures at school or home, since children in this age range are often starting to compare themselves to peers and may be internalizing the challenge of simply managing their bodies.

Treatment continues to prioritize parent and caregiver education. Again, teaching parents to support without pressure to correct everything, and building in opportunities to learn together. I focus heavily on positive reinforcement and like to demonstrate positions of instability to the parent directly, so they can recognize and reinforce more stable, desired positions at home.

This is also the age where I focus on building confidence around handwriting specifically. Plastic splints, such as oval-8 splints, silver ring splints, or simple pencil grips, can support finger joints and improve endurance during handwriting and computer work. I also encourage taking regular breaks to prevent extreme fatigue, which can otherwise lead to complaints of pain or burnout. And I like to help families build a home movement routine that includes weight-bearing positions with attention to spinal alignment, empowering the child to notice which positions feel easy versus which feel difficult to maintain, as well as increasing awareness around breathing and mid-body stability. Kids in this age range can genuinely learn where their breath travels in their body and how to use that breath to keep their core engaged and strong.

Teens: Ages 13 to 18

Again, if hypermobility hasn't been recognized in earlier years, it will continue to progress into the teenage years, sometimes with more persistent, widespread pain throughout the body. This is often the age when families finally seek out a diagnosis, because a parent notices their teen struggling with a specific task, or the teen themselves starts to voice that certain things feel harder than they should be. Watch for poor endurance with writing, computer, tablet, or phone use; persistent, widespread pain; difficulty concentrating in school; and continued clumsiness, with an increased risk of injury, bruising, or scarring if there's tissue involvement.

For assessment, I want to center the conversation on what the teens themselves find bothersome. This builds a real sense of trust and safety, because we're showing them that their feelings and experiences are valued. From there, continue using the Beighton Scale, and consider adding range of motion and manual muscle testing to assess joint laxity and instability more specifically. Watch for intentional joint cracking or popping, which is very common in this population, especially in the neck and fingers. Notice whether the teen has difficulty finding or maintaining a comfortable position, since constant adjusting can signal an underlying difficulty finding stability in their own body. Observe them across multiple positions like seated, standing, supine, quadruped, and side-lying, to see how their bodies transition and manage themselves along the way.

Treatment at this stage still involves parent and caregiver education, but the emphasis shifts. It becomes just as important to empower teens to understand their own bodies, while giving parents room to support without taking over their problem-solving. Creating an environment of safety and genuine belief in what the teen is experiencing is essential here.

I like to educate teens directly on their own positions of instability, sometimes literally taking photos to show them the difference between an unstable and a stable position, and talking through the "why" behind changing those positions: to decrease pain, to improve stability, and to improve their ability to participate in the activities they actually enjoy. Building a home movement routine remains valuable here too, with continued focus on breathing and body stability, and helping teens develop a clearer understanding of where sensations and instability show up in their own bodies, which builds both safety and a sense of agency.

I also spend time educating teens about the different tools available for varying levels of support: silver or plastic splints for finger stability, popsocket-style or other phone supports to reduce repetitive strain, and posture-support garments to improve tolerance throughout a full school day. And I like to build in an energy conservation routine for after school — things like elevating the legs against a wall, performing ankle pumps, listening to relaxing music, or simply creating a calm, quiet space to decompress after what has often been a demanding day for their whole system, whether that system involves joint hypermobility alone or a more systemic connective tissue presentation.

A Note on Grip Patterns Across Development

Something I want to name explicitly, because it comes up so often in my own hand-therapy-focused practice, is how differently hypermobility can show up in grip and pencil-hold patterns as a child moves from toddlerhood into school age. In a school-aged child, I frequently see hyperextension at the interphalangeal joint of the thumb during a pencil grasp — what I sometimes describe as a "D-shaped" position, where I would much rather see a rounded "C-shape" forming between the thumb and index finger. I'm typically less concerned about a slightly unconventional grip on a crayon or a piece of chalk during play, and much more focused on that small, overloaded joint at the base of the thumb absorbing all of the pressure during sustained tasks like handwriting or completing a worksheet. These are the kinds of small, easy-to-miss details that are worth documenting and monitoring over time, because they tend to compound as academic demands increase.

Questions 

How do you specifically communicate with a pediatrician regarding a patient?

I've been working hard on this. I've developed relationships with a group of pediatricians in my area and have met with a couple of pediatric teams to educate them on what we've covered today. Often, pediatricians simply don't have the time. They may have only 15 minutes for a well-child visit and may not be able to connect all the pieces in that window. So I've offered to do a lunch-and-learn with physician groups, sharing that this information is clinically evidence-based and useful. As therapists, we can complete the diagnostic scoring ourselves, which takes one task off the physician's plate. I'll often fill out the Beighton Scale scoring, or the hEDS diagnostic form, and either fax it to the physician directly or send it home with the family to bring to their appointment. This gives the pediatrician clear information about what I'm seeing and helps move the plan of care forward more efficiently.

Which specialists do you typically refer to?

Most often, rheumatology. In Ohio, we're fortunate to have a hypermobility clinic at our children's hospital, and I have a physician contact there that I frequently recommend patients to. That's generally my strongest line of connection for further diagnostic workup.

A caregiver mentioned a two-and-a-half-year-old with low tone and knee hyperextension who saw a neurologist and had an uneventful blood test. Who diagnoses these children?

A standard blood test would not rule out EDS. Diagnosing hEDS specifically requires a geneticist and a genetic panel, though hEDS itself does not yet have an identified genetic marker, unlike other EDS subtypes, which do have identified genetic mutations. For a child this young, getting a formal EDS diagnosis can be more challenging. If there's a concern that something beyond hypermobile EDS may be present, genetic testing can still be pursued to look for other EDS-related mutations. A geneticist is typically the right specialist here, and if you have a children's hospital nearby, many are now developing dedicated hypermobility clinics given how much research is emerging in this space.

Do you have recommendations for assessing hypermobility in the autism spectrum population within schools?

Observation is key here, using the same categories we've discussed throughout this course. Give the child a task and watch how their joints manage it. They may avoid positions that feel uncomfortable, and depending on where they fall on the communication spectrum, they may or may not have the language to describe why. I like to offer movement strategies to try, or mimic and play through movements I want to observe, watching how their joints stabilize in response. When implementing intervention, I'm often right down on the floor with them, offering verbal cues, visual cues, and, with permission from both the patient and their parent, tactile cues to their body, incorporating sensory integration techniques when the child can tolerate them. This tends to be a more informal assessment process, but I'm still completing the same diagnostic forms and gathering information from parents alongside my own range-of-motion observations.

Conclusion

Hypermobility exists on a wide spectrum. It can range from a single hypermobile joint to a full connective tissue disorder that touches joints, ligaments, organs, and tissue throughout the body. As occupational therapy practitioners, it's important for us to build a working understanding of this diagnosis, how it presents differently across the pediatric age range, and the comorbidities that may accompany it, so we can provide the most complete, thoughtful level of care possible.

If you're seeing patients with hypermobility, use the assessment tools available to you to determine the level and type of hypermobility present. Give yourself space to zoom out and look at the whole individual, rather than just the joint in front of you, because the co-morbidities we've discussed today are often just as important to the child's daily function as the joint symptoms themselves. Collaborate with parents, caregivers, and teachers, and create opportunities for everyone involved to learn together. Build a plan of care that allows room for modification and adjustment as the child's needs evolve, with education always at its center. And whenever possible, build a local network of providers so your patients have access to support beyond our scope as OTPs.

Ultimately, hypermobility awareness starts with us noticing the little things, the avoided positions, the subtle grip patterns, the child who seems a little more tired than their peers. The earlier we can recognize these patterns, the sooner we can help these children, and eventually adults, find real stability, confidence, and agency in their own bodies.

I think about the ten-to-twenty-year average diagnostic delay I mentioned earlier and how much of that gap we, as OTPs, are positioned to help close. We are often in the room with these children more consistently and for longer stretches of time than almost any other provider on their care team. We see them move, play, write, and struggle in ways that don't always make it into a fifteen-minute physician visit. That access is a genuine privilege, and I hope today's course has given you a stronger foundation for using it well, not to diagnose, but to notice, to document, to ask thoughtful questions, and to build the kind of collaborative care network that helps a hypermobile child grow into an adult who understands, trusts, and feels supported in their own body.

References

See additional handout.