Estimated reading time: 6 minutes The hip joint is one of my favourite joints – although it can be a cause of many problems in hypermobility. It is such a key joint in the body – it is one of the largest and most important joints for several reasons.
- It is a weight-bearing joint during standing, walking, and running.
- It transfers weight from the upper body to the lower limbs too.
- It has a wide range of mobility in multiple directions – it can flex, extend, abduct, adduct, and internally and externally rotate
- It is designed to provide a lot of stability.
- The ball and socket joint, like the shoulder joint, offers mobility but strong ligaments and muscles around the hip should provide stability. We know of course this may not always be the case in hypermobility.
- The hip joint has an important postural role too – it helps with the balance of the pelvis and spine on top of the legs. It helps keep equilibrium when moving.
- Finally, it is a shock absorber that distributes forces through the whole structure during movement.
Lack of movement at the hip joint can have big implications for our movement and pain levels, as I know personally.
Back in 2010, I tore my right hip labrum whilst attempting a beginner ski lesson. I developed instability in the hip joint which then led to low back pain. My low back muscles had to start working much harder to compensate for the lack of stability on that hip. After a thorough assessment, I was advised to undergo surgery (this was before my EDS diagnosis) and the surgery was a huge success. My back pain resolved almost instantly, and my hip pain and impingements disappeared. A few months of physical therapy rehabilitation, walking on crutches, and not loading the joint followed the operation. Today, the hip is much stiffer and lacks the mobility it had, but it is pain-free and stable.
In 2016, I tore the left hip labrum. This time I decided not to go for surgery and try the rehab-only route. This included lots of hip stabilization, foot-to-hip connection, and whole-body integration. I managed to get it under control. Of course, everyone is different, and surgery may be the only option in some cases.
What is Hip Hypermobility?
Hip hypermobility is defined as excessive range of motion in the joint. Hypermobility can happen without pain and other symptoms – you can be hypermobile and stable. However, when symptoms related to hip hypermobility are present, hip instability is considered (1).
Hip hypermobility can be due to inherited connective tissue disorders like EDS and HSD, or can be a result of micro or macro-trauma to the joint like injury or dislocations (1). Authors of a review paper focusing on hip hypermobility state “hypermobility is becoming an increasingly recognized source of pain and instability of the hip Joint (1).” I am glad this is being recognized.
Let’s take a look at the anatomy of the hip joint. The hip joint is a ball and socket with the head of the femur (ball) articulating with the acetabulum (socket) of the pelvis. As mentioned above, the joint allows for flexion and extension of the leg, internal and external rotation of the thigh, and abduction (away from the center of the body) and adduction (towards the center of the body). It is also involved in supporting the weight of the trunk and transmitting force for walking (2). There 3 ligaments that form the capsule around the joint ( the iliofemoral ligament, pubofemoral ligament, and ischiofemoral ligament).
At the point of connection between the socket and the head of the femur is the labrum composed of fibrous cartilage. This cartilage surrounds the rim of the acetabulum or socket part of the hip. It serves as a shock absorber, helps with stability, lubricates, and distributes pressure in the joint (3).
Hip Issues associated with hypermobility
Anecdotally my clients and members of The Zebra Club report hip pain regularly. We explored the literature and found some instances of common hip issues in the context of hypermobility. This list is not exhaustive, nor will these affect every person with hypermobility.
- An observational study on patients with hip or knee pain found hypermobility was high in this group (43.2%). The percentage of patients being hypermobile was even higher in patients that had hip dysplasia (66.7% based on the Beighton score or 83.3% based on the Hakim-Grahame criteria) (4)
- Femeroacetabular impingement syndrome (FIAS) seems more common in hypermobility (especially in dancers with external rotation). This happens when there is abnormal contact of the femoral head (ball) with the edge of the socket (acetabulum) (1, 5).
- Labral tears are thought to be more common in EDS (6). One small study (34 total patients with FIAS) found that patients with a generalized joint hypermobility had significantly thinner labrum when assessed by MRI (7).
- Lateral hip pain from the iliotibial band subluxing over the trochanter of the femur. This is described as “painful, loud clunking sensation” and may contribute to trochanteric bursitis and pain sleeping on the side. Authors state this clunking is sometimes interpreted as a dislocation, though it is not (6).
- SI joint instability (though not the hip joint itself) is considered “very common” with physical therapy being the first recommendation for relief (6).
The Connection Between Hip Hypermobility and Joint Pain
In many sports like gymnastics and dance – hip hypermobility is of benefit and even necessary at high levels of performance or competition. However, repetitive loading at extreme ranges of motion can contribute to instability of the joint (1).
Ultimately, instability leads to an increased risk of dislocations and subluxations with soft tissue injuries and joint pain. Microtrauma (subtle injuries that may build up over time leading to pain) as a result of instability may lead to persistent joint pain. For example, repetitive microtrauma with occasional macrotrauma (like a dislocation or other large injury) may contribute to labral tears (8).
Managing Hip Hypermobility and Joint Pain
The good news is we can address instability and pain through movement therapy.
- Address potential central sensitization and nociplastic pain
- Address the feet: the foot-to-pelvis relationship is super key. The hip is impacted by the alignment of the foot, so any misalignment at ground level is going to impact the hip.
- Strengthening the muscles around the pelvis will help – glutes and hip flexors are key.
- Balance and proprioception exercises can be really helpful in understanding our posture and alignment.
- Avoid movements that cause impingement pain or put excessive stress on the hip joint. Hugging the knees to the chest can cause impingement pain. High-impact sports and activities could be avoided.
- Orthotics and braces can be helpful to support the hip joint.
- Use good supportive footwear to ensure the hip gets good support from the ground up. Sophie Roberts gave a great talk on podiatry for The Zebra Club members that can be found in the resources section of the app.
- Working on whole body integration exercises – how does the hip relate to other joints? It is not isolated in its function.
We have a whole collection of classes in The Zebra Club to address the hips. You can find it in the programs section under Hips and Pelvis
Improving Joint Health with Hip Hypermobility
Gait can be significantly impacted by hip joint instability due to the hip joint’s role in alignment, balance, proprioception, and strength. We may start to see altered gait patterns as we compensate for the lack of strength and stability in the hip. Limping, uneven stride lengths, and lack of hip extension are something I commonly observe.
You may feel stiff in your hips which leads to a gait pattern that is less smooth as the weight of the body is transferred from one leg to another. It makes sense – if you have hip pain, you are unlikely to want to put weight through that joint – even at a subconscious level. Your body will find a compensatory pattern to avoid the hip. This of course will then load other joints and may lead to pain in other areas. The whole body can be impacted and we may start to see muscle imbalances and pain.
Hip instability may make people fearful of falling. A recent study found that fear of falling in hypermobile patients was a very limiting factor and predictor for disability (9).
When to Seek Professional Help
At the Ehlers-Danlos Society Global Learning Conference this summer, Dr. Dacre Knight said it is a good idea to see your doctor if anything is new, different, or profound. This is a great rule of thumb when it comes to seeking care. Proper assessment and treatment of hip instability is important so that other joints do not start to compensate for it. Physical therapy is often recommended, as well as orthotics and braces to support as needed.
If you want to dive deeper into movement for the hips check this live class I did all about Stabilizing Hypermobile hips. Another video you may find helpful is The Best Exercises for Hip and Low Back Pain from my 5-a-day video series.
Research and Literature Review by Catherine Nation, MSc, PhD
Works Cited
1. Clapp, et al (2021). Hypermobile Disorders and Their Effects on the Hip Joint. Frontiers in Surgery.
2. Gold, et al (2023). Anatomy, Bony Pelvis and Lower Limb, Hip Joint. National Library of Medicine StatPearls.
3. https://www.physio-pedia.com/Hip_Anatomy
4. Muldoon, et al (2016). Hypermobility: a Key Factor in Hip Dysplasia. A Prospective Evaluation of 266 Patients. Journal of Hip Preservation Surgery.
5. Weber, et al (2015). The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast. Sports Health.
6. Ericson, Jr & Wolman (2017). Orthopaedic management of the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C (Seminars in Medical Genetics)
7. Haskel, et al (2021). Generalized Joint Hypermobility Is Associated With Decreased Hip Labrum Width: A Magnetic Resonance Imaging-Based Study. Arthroscopy, Sports Medicine, and Rehabilitation.
8. Castori, et al (2017). A framework for the classification of joint hypermobility and related conditions. American Journal of Medical Genetics Part C (Seminars in Medical Genetics).
9. Chuchin & Ornstein (2023). Fear avoidance, fear of falling, and pain disability in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. Disability and Rehabilitation.
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