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30 SECONDS OF THERAPY: Lower Extremity in Hypermobility Spectrum Disorder (HSD) and Ehlers-Danlos Syndrome (EDS)

May 12

9 min read

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START


  1. Screen for subluxations and asymmetries

    1. HSD/EDS is a rare connective tissue disorder that causes joint hypermobility,  subluxations,  instability, pain. 

    2. Standing and seated flexion tests for sacral and ilium torsions

    3. Marching test/Gillet test (sensitivity 43%) for sacral excessive mobility

    4. Palpation for guarded piriformis, iliopsoas, pubis indicating joint instability.

    5. Lower Limb Assessment Score for hypermobility patterns (e.g., knee hyperextension >3 cm, subtalar inversion >45°, MTP DF >90°)

      USe the download assessment on our website and (https://www.ehlers-danlos.com/assessing-joint-hypermobility/)


  2. Incorporate long-hold techniques and muscle energy, since hypermobile joints need stabilization before mobilization.

    1. Long-hold joint glides (90 sec) to reduce autonomic tone and guarding. 

    2. Muscle energy techniques (MET) using agonist contraction e.g., hamstrings for anteriorly rotated ileum, iliopsoas for sacral torsion.

    3. Positional release for sharp, bruised pain at tender points.


  3. Start teaching self-correction and movement strategies to empower patients with simple home tools.

    1. Anterior hip subluxation: ankle-on-knee MET with resisted abduction.

    2. Upslip: quick pull “sneeze” method (avoid if anterior impingement)

    3. Talus anterior subluxation: strap-pull DF correction against wall or opposite foot.


STOP


  1. Stop over mobilizing lax structures, as patients with HSD/EDS often experience joint instability, not stiffness

    1. Avoid Grade V mobilizations in unstable segments.

    2. Prefer long-hold MFR or gentle glides for autonomic-driven tone.

    3. Overmobilization can increase pain sensitization and fear of movement.


  2. Progressing patients based on time alone.

    1. Posterior hip subluxation: avoid deep squats, leg press, sit-to-stand initially.

    2. Anterior hip subluxation: avoid straight leg raises in supine without cuing for glute contraction.

    3.  Initially avoid excessive use of gluteal muscles. Strengthen the hip flexor and abdominals. Start gluteal work in protected positions — Have the hip in extension and possibly ER.


  3. Stop Ignoring the kinetic chain, as even minor misalignments can impact the whole body.

    1. A posteriorly displaced fibula can mimic medial knee pain.

    2. Anterior talus subluxation limits DF and alters knee and hip mechanics.

    3. Realign the pelvis, hip, tib/fib, and foot before loading.


WHY


  1. Why Do Lower Extremity Issues in HSD/EDS Cascade?

    1. Joint instability is not isolated. A single subluxation (e.g., anterior hip) alters biomechanics up and down the chain—from the pelvis to the foot—leading to secondary pain and motor guarding in surrounding joints.


  2. Why Prioritize Stabilization Before Mobilization?





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