Is There a Connection Between Hypermobility and Fibromyalgia?

Understanding Hypermobility and Fibromyalgia

What Is Hypermobility?

Joint hypermobility refers to an increased range of motion in the joints beyond what is considered normal. While some individuals are naturally more flexible, hypermobility can sometimes lead to pain, instability, and other musculoskeletal issues. It is important to differentiate between generalised hypermobility, which may be harmless, and hypermobility syndromes that can cause significant health complications.

Generalised Hypermobility vs. Hypermobility Syndromes

• Generalised Joint Hypermobility (GJH): This is a benign condition where a person’s joints have an extended range of motion. It does not necessarily cause pain or health problems. Many dancers, gymnasts, and athletes have generalised hypermobility without experiencing symptoms.
• Hypermobility Spectrum Disorders (HSDs): These include various forms of hypermobility where symptoms such as chronic pain, joint instability, and fatigue are present.
• Joint Hypermobility Syndrome (JHS): A condition where hypermobility leads to joint pain, dislocations, and fatigue. It is often considered a precursor to hypermobile Ehlers-Danlos Syndrome (hEDS).
• Ehlers-Danlos Syndrome (hEDS): A genetic connective tissue disorder associated with joint hypermobility, skin elasticity, and fragile tissues. hEDS is a severe form of hypermobility that can lead to chronic pain, gastrointestinal issues, and cardiovascular complications.

Common Symptoms and Associated Conditions

People with hypermobility often experience:

• Frequent joint dislocations or subluxations
• Chronic joint pain and stiffness
• Fatigue and muscle weakness
• Soft, stretchy skin (in some cases)
• Gastrointestinal issues such as irritable bowel syndrome (IBS)
• Autonomic dysfunction, including dizziness and fainting (commonly seen in Postural Orthostatic Tachycardia Syndrome – POTS)

Since hypermobility affects the connective tissues throughout the body, it can lead to widespread symptoms beyond the joints. Many individuals with hypermobility-related disorders also report increased sensitivity to pain, a characteristic that overlaps with fibromyalgia.

The Link Between Hypermobility and Fibromyalgia

Overlapping Symptoms

While hypermobility and fibromyalgia are distinct conditions, they share a range of symptoms that can make diagnosis and management challenging. Many individuals with hypermobility spectrum disorders (HSDs) or hypermobile Ehlers-Danlos Syndrome (hEDS) report symptoms that closely resemble fibromyalgia, leading researchers to explore potential connections between the two.

Chronic Widespread Pain

Both hypermobility and fibromyalgia are characterised by persistent musculoskeletal pain. In hypermobility, joint instability and excessive movement can lead to micro-injuries, strain on muscles and tendons, and early-onset joint degeneration, all of which contribute to pain. In fibromyalgia, pain is thought to arise from abnormalities in how the nervous system processes pain signals, known as central sensitisation.

People with hypermobility-related disorders often experience:

• Frequent joint and muscle pain due to excessive joint movement.
• Increased pain sensitivity (hyperalgesia) in response to minor injuries or pressure.
• Diffuse, non-specific pain that overlaps with fibromyalgia’s widespread pain patterns.

Fatigue and Sleep Disturbances

Severe fatigue is a hallmark symptom of both conditions. In fibromyalgia, disrupted sleep patterns, particularly non-restorative sleep, contribute to exhaustion. Similarly, people with hypermobility often experience sleep disturbances due to chronic pain, muscle tension, and nocturnal joint instability. Studies suggest that the autonomic nervous system (ANS) plays a role in sleep regulation, and dysfunction in this system can result in poor sleep quality.

Autonomic Dysfunction (Dizziness, Heart Rate Irregularities)

Both fibromyalgia and hypermobility syndromes are associated with dysautonomia, a dysfunction of the autonomic nervous system, which regulates involuntary bodily functions such as blood pressure, heart rate, and digestion. Common autonomic symptoms seen in both conditions include:

• Postural Orthostatic Tachycardia Syndrome (POTS): A condition where standing up causes an abnormal increase in heart rate, leading to dizziness and fainting.
• Blood pressure instability: Some individuals experience sudden drops in blood pressure, leading to lightheadedness.
• Gastrointestinal issues: Symptoms such as irritable bowel syndrome (IBS) and slow digestion are prevalent in both conditions.

The overlap in these symptoms suggests a shared underlying mechanism that connects hypermobility and fibromyalgia at a deeper physiological level.

Shared Underlying Mechanisms

Nervous System Dysfunction: Role of Central Sensitisation

Central sensitisation is a key factor in fibromyalgia and may also play a role in hypermobility-related disorders. This phenomenon occurs when the nervous system becomes hypersensitive to pain, amplifying signals that would not typically be painful. In both fibromyalgia and hypermobility, this heightened pain response is often accompanied by:

• Allodynia (pain from normally non-painful stimuli, such as light touch).
• Hyperalgesia (increased pain perception to minor injuries).
• Chronic widespread pain that does not correspond to physical injury.

Research suggests that people with joint hypermobility may be more prone to nociplastic pain, a type of pain generated by the nervous system rather than from actual tissue damage. This aligns with fibromyalgia, where pain is largely due to alterations in how the brain and spinal cord process pain signals.

Collagen and Connective Tissue Issues: Impact on Musculoskeletal Pain

Collagen, the protein that provides structural integrity to connective tissues, may be a crucial link between hypermobility and fibromyalgia. Many hypermobility syndromes involve collagen abnormalities, leading to:

• Joint instability and chronic musculoskeletal pain.
• Increased laxity in ligaments and tendons, making them prone to micro-tears.
• Soft tissue injuries that heal slowly and contribute to long-term pain.

Although fibromyalgia is not classified as a connective tissue disorder, collagen abnormalities may predispose individuals to chronic pain by affecting the musculoskeletal system’s structural integrity. Some researchers theorise that fragile connective tissues in hypermobile individuals may trigger nociceptive pain (pain caused by actual tissue damage) that later develops into central sensitisation, as seen in fibromyalgia.

Dysautonomia: How Autonomic Nervous System Dysfunction Contributes to Symptoms

The autonomic nervous system (ANS) is responsible for regulating bodily functions such as heart rate, blood pressure, digestion, and temperature control. Both hypermobility syndromes and fibromyalgia frequently involve ANS dysfunction, contributing to a wide range of symptoms:

• POTS and Orthostatic Intolerance: Many hypermobile individuals and fibromyalgia patients experience rapid heart rate increases upon standing, causing dizziness and fainting.
• Temperature Sensitivity: Poor regulation of body temperature, leading to excessive sweating or cold extremities.
• Fatigue and Exercise Intolerance: Blood pooling in the lower extremities may reduce oxygen flow to muscles, exacerbating fatigue and pain.

Dysautonomia may be the missing link explaining why hypermobile individuals experience symptoms commonly seen in fibromyalgia. A dysfunctional ANS may contribute to both chronic pain and fatigue, reinforcing the idea that these conditions share overlapping mechanisms.

Prevalence of Fibromyalgia in People with Hypermobility

Studies Linking Hypermobility Syndromes to Increased Fibromyalgia Risk

Several studies have identified a higher prevalence of fibromyalgia among individuals with hypermobility-related disorders. Research suggests that people with hEDS or JHS are significantly more likely to be diagnosed with fibromyalgia than the general population. Some key findings include:

• A 2017 study published in Rheumatology International found that individuals with hEDS had a fourfold increased risk of developing fibromyalgia.
• A 2015 study in The American Journal of Medical Genetics reported that up to 80% of hEDS patients met the diagnostic criteria for fibromyalgia.
• A 2020 review in Clinical Rheumatology highlighted that both conditions frequently co-exist and may stem from a shared pathophysiological mechanism involving nervous system hypersensitivity.

Higher Pain Sensitivity in Hypermobile Individuals

People with joint hypermobility often exhibit enhanced pain perception, a trait that overlaps with fibromyalgia. This increased pain sensitivity may stem from:

• Lower pain threshold: Hypermobile individuals often feel pain more intensely and for longer durations.
• Altered proprioception: A reduced ability to sense joint positioning, leading to repetitive strain and injuries.
• Chronic muscle tension: Due to joint instability, the muscles surrounding hypermobile joints often work harder to compensate, leading to pain and fatigue.

Since pain is a dominant feature in both conditions, individuals with hypermobility syndromes may be more susceptible to developing fibromyalgia-like symptoms, reinforcing the idea of a connection between the two disorders.

Diagnosing and Managing Hypermobility and Fibromyalgia Together

Diagnostic Challenges

Diagnosing hypermobility and fibromyalgia together presents unique challenges due to their overlapping symptoms, which can lead to misdiagnosis or delayed recognition of both conditions. Patients often report widespread pain, fatigue, and autonomic dysfunction, making it difficult for healthcare providers to determine whether symptoms stem from joint instability (hypermobility) or central sensitisation (fibromyalgia).

Overlapping Symptoms Making Diagnosis Difficult

• Chronic pain: Both conditions involve persistent musculoskeletal pain, but in hypermobility, pain often originates from joint instability, whereas fibromyalgia pain is associated with central nervous system dysfunction.
• Fatigue: Disrupted sleep due to pain, autonomic dysfunction, and muscle strain is common in both disorders.
• Autonomic symptoms: Dysautonomia, including dizziness, heart rate irregularities, and digestive issues, is frequently seen in both fibromyalgia and hypermobility spectrum disorders.
• Psychological impact: Anxiety, depression, and cognitive dysfunction (“fibro fog”) can occur in both conditions, further complicating diagnosis.

Criteria for Identifying Hypermobility-Related Disorders

Since generalised joint hypermobility is a common trait, clinicians use specific criteria to determine whether hypermobility is part of a broader disorder.

Beighton Score

The Beighton Score is a widely used tool to assess joint hypermobility. It evaluates flexibility in nine different movements, assigning a score based on the number of hypermobile joints. A higher score suggests greater joint laxity. The criteria include:

1. Ability to bend the pinky finger back beyond 90 degrees (1 point per hand).
2. Ability to bend the thumb to touch the forearm (1 point per hand).
3. Hyperextension of the elbows beyond 10 degrees (1 point per elbow).
4. Hyperextension of the knees beyond 10 degrees (1 point per knee).
5. Ability to place hands flat on the floor without bending knees (1 point).

A total score of 5 or more (out of 9) in adults or 6 or more in children suggests generalised joint hypermobility. However, additional diagnostic criteria are required to confirm a hypermobility syndrome such as hEDS or Joint Hypermobility Syndrome (JHS).

For fibromyalgia, diagnosis is based on widespread pain criteria and symptoms of central sensitisation, such as allodynia (pain from non-painful stimuli) and fatigue. Since no single test confirms either condition, diagnosis often relies on clinical history, symptom patterns, and ruling out other disorders.

Treatment Strategies

Although hypermobility and fibromyalgia have different underlying causes, treatment often overlaps, focusing on pain management, strengthening the body, regulating the nervous system, and improving overall quality of life. A multidisciplinary approach is the most effective way to manage symptoms.

Transcranial Magnetic Stimulation (TMS)

• TMS is a non-invasive brain stimulation therapy that has shown potential in reducing central sensitisation and chronic pain.
• Studies suggest TMS may help “reset” pain pathways in fibromyalgia and improve cognitive function.

Pain Management: Medication Options for Both Conditions

Since pain in hypermobility is typically due to joint instability and muscle strain, while fibromyalgia pain stems from nervous system hypersensitivity, treatment strategies need to target both mechanisms.

Common Medications for Pain Relief:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Useful for hypermobility-related joint pain but often ineffective for fibromyalgia.
• Tricyclic Antidepressants (Amitriptyline, Nortriptyline): Help reduce fibromyalgia pain, improve sleep, and relieve muscle tension.
• Gabapentinoids (Gabapentin, Pregabalin): Often prescribed for fibromyalgia to reduce nerve pain and central sensitisation.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) (Duloxetine, Venlafaxine): Beneficial for both conditions, helping with pain modulation and fatigue.
• Muscle Relaxants (Cyclobenzaprine, Baclofen): May help ease muscle tension and prevent painful spasms.
• Low-Dose Naltrexone (LDN): An emerging treatment option for fibromyalgia, thought to reduce neuroinflammation and pain sensitivity.

Physical Therapy: Strengthening and Stabilisation Techniques

For hypermobility:

• Proprioceptive training (awareness of joint positioning) to improve coordination and prevent joint injuries.
• Low-impact strength training to stabilise hypermobile joints and reduce muscle overcompensation.
• Core strengthening exercises to support spinal stability and prevent postural issues.
• Hydrotherapy (aquatic therapy), which reduces stress on the joints while improving muscle strength.

For fibromyalgia:

• Gentle stretching and myofascial release to prevent muscle stiffness.
• Graded exercise therapy (GET) to gradually build endurance without triggering pain flares.
• Tai chi and yoga, which have been shown to improve pain, fatigue, and balance in fibromyalgia patients.

Since individuals with hypermobility are prone to joint subluxations and dislocations, therapy must be gentle and controlled, avoiding high-impact activities that may worsen symptoms.

Lifestyle Adjustments: Sleep Hygiene, Diet, and Pacing Activities

Improving Sleep Quality:

• Maintaining a consistent sleep schedule.
• Using weighted blankets for deep pressure stimulation, which can calm the nervous system.
• Avoiding screen time before bed to prevent melatonin disruption.

Dietary Modifications:

• Anti-inflammatory diet rich in omega-3 fatty acids, lean proteins, and fresh vegetables.
• Avoiding processed foods, sugar, and excessive caffeine, which can exacerbate pain and fatigue.
• Magnesium supplementation, which may help with muscle relaxation and nerve function.

Pacing and Energy Management:

• Using the “Spoon Theory” to allocate energy efficiently throughout the day.
• Implementing activity modification techniques, such as taking breaks and avoiding repetitive joint stress.
• Prioritising low-impact hobbies to stay active without triggering symptom flares.

Mental Health Support: Cognitive Behavioural Therapy (CBT) for Coping with Chronic Pain

The emotional toll of living with chronic pain can lead to anxiety, depression, and emotional exhaustion. Cognitive Behavioural Therapy (CBT) is widely recommended for both hypermobility and fibromyalgia as it:

• Helps manage pain-related distress by changing negative thought patterns.
• Teaches coping strategies for dealing with daily physical limitations.
• Reduces fear-avoidance behaviours, encouraging individuals to stay active in a way that suits their body’s needs.

Other beneficial mental health approaches include mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), and guided relaxation techniques.

When to See a Specialist

Since many general practitioners (GPs) are unfamiliar with the complexities of hypermobility and fibromyalgia, individuals often need to see a specialist for proper management.

Signs That Require Medical Intervention

• Severe joint instability that leads to frequent dislocations or chronic pain.
• Unexplained fainting, dizziness, or rapid heart rate changes, which may indicate dysautonomia.
• Progressive muscle weakness or numbness, which may require further neurological evaluation.
• Severe sleep disturbances, extreme fatigue, or cognitive impairment that impact daily functioning.

The Role of Rheumatologists and Pain Specialists

• Rheumatologists: Specialise in connective tissue disorders, autoimmune diseases, and fibromyalgia. They can differentiate between hypermobility syndromes and inflammatory conditions such as rheumatoid arthritis.
• Pain Specialists: Help develop comprehensive pain management plans using medication, physical therapy, and alternative treatments.
• Neurologists: Assess neurological symptoms, particularly in cases of autonomic dysfunction or suspected central sensitisation disorders.
• Physiotherapists and Occupational Therapists: Assist in joint protection strategies, mobility adaptations, and exercise modifications tailored to each individual’s needs.