Understanding shoulder hypermobility

It’s not surprising that the most mobile joint in our bodies could have some issues if we have hypermobile Ehlers-Danlos Syndrome (hEDS) or Hypermobility Spectrum Disorder (HSD).

While there is no gold standard treatment for shoulder hypermobility, the good news is there is so much we can do to stabilize the joint. A mistake often made when treating individuals with shoulder hypermobility is to jump straight in with strengthening work with weights, bands, and bodyweight exercises like planks and bird dog. This rarely works in my experience.

I take a very different approach that starts with foundational work to increase body awareness, reduce stress and tension around the joint, and then find a true understanding of arm mechanics. This is when I start to see my clients find shoulder stability.

Anatomy and functions of the shoulder

Understanding the shoulder joint’s structure can help us understand how we move. It is a ball and socket joint, with the head of the humerus (ball) sitting in the glenoid fossa (socket) of the scapula (shoulder blade). This joint is normally stabilized by several ligaments and muscles. This ball and socket allow for a large range of motion in multiple directions moving over 270 degrees (3).

This sounds great, and it can be hugely beneficial for many sports and activities like swimming, cricket, gymnastics, and ballet. However, the design of the joint sacrifices stability for mobility. The head of the humerus can be four times bigger than the socket in surface area (2). It doesn’t fit into it deeply but rather ‘hangs’ from the socket.

This range of motion means the shoulder is capable of various movements including:

• Flexion which means raising the arm forward
• Extension which is lowering the arm backward
• Abduction which involves moving the arm away from the body
• Adduction involves bringing the arm toward the body
• Internal rotation means rotating the arm bone inwards
• External rotation where we rotate the arm outwards

The shoulder can also perform circumduction which is the combination of flexion, extension, abduction and adduction. This allows us to draw a circle with our arm – which is great for movements involved in swimming, bowling in cricket or baseball, gymnastics, and more.

Effect of hypermobility in the shoulder

If the ligaments and muscles are strong, resilient, and have the stability to hold that bone in place, then the structure has integrity. But if you have a connective tissue disorder causing ligament laxity and low muscle tone, you can see how there could be a potential structural and mechanical issue. We need stability surrounding the shoulder joint to hold it in place and to move safely.

Liaghat et al (2022) found that pathology in a variety of shoulder structures could be responsible for painful shoulder conditions in people with hypermobility. This included rotator cuff muscles and tendons, the shape of the acromion, and the capsular or ligamentous tissues.

The laxity in both the capsules and the ligaments can potentially lead to subluxations and dislocations (3). Not surprisingly, if we have recurring injuries we can start to see asymmetric loading or use of the joint (3).

One group wanted to characterize the shoulders of people with hEDS/HSD with multidirectional shoulder instability (MDI). MDI is characterized by increased laxity in over two directions and involuntary shoulder subluxations. They found altered scapular movement patterns (scapular dyskinesia) and increased muscle activation in some of the muscles around the shoulders. They hypothesize the increased muscle activation was the result of the body trying to stabilize the shoulder (4). This fits with the altered movement patterns I often see in clients, we need to reduce tension as well as stabilize.

In one study on self-reported pain patterns in people with joint hypermobility, pain was reported in the shoulder in 80.8% of respondents, second only to the neck (90.4%). They also reported significantly lower shoulder function and physical health-related quality of life than non-hypermobile controls (5). If you struggle with pain in your shoulders, you are not alone!

Common conditions in hypermobile shoulders

Here are just some of the common issues my clients have reported with hypermobile shoulders.

• Subluxations and dislocations
  • The shoulder is the joint that experiences the most dislocations (2).
• Labral Tears
  • This is damage to the ring of cartilage that surrounds the socket of the shoulder joint. Physical therapy or surgery may be needed in some severe tears.
• Bicep tendon pathology
  • This refers to any condition or injury affecting the biceps tendon which connects the biceps muscle to the shoulder and elbow joints.
• Glenohumeral instability
  • Excessive movement at the glenohumeral joint (top of the arm bone within the socket).
• General Joint pain
  • Many people have widespread joint pain and shoulder joint pain for no evident reason.
• Shoulder Impingement
  • This occurs when the tendons or bursa in the shoulder become compressed or pinched between the bones of the shoulder. Overhead activities or repetitive shoulder movements can lead to irritation, inflammation, and pain.
• Frozen shoulder
  • This presents as stiffness, pain, and limited range of motion in the shoulder joint. It develops gradually over time.
• Rotator cuff injury and tears
  • These can be more common in people with hypermobility due to the increased flexibility and range of motion. The instability can make the rotator cuff more susceptible to overuse injuries and strains.
• Scapular dyskinesia presents as winging scapula and altered movement patterns
  • This refers to abnormal movement or positioning of the shoulder blade during shoulder movements. Poor mechanics can lead to pain, weakness, and imbalances.
• Upper back tightness
  • Also often referred to as Coathanger pain – it is a specific type of pain felt in the shoulders and upper back resembling the shape of a coathanger.
• Neck and Jaw Pain
  • This seems very common with unstable shoulder joints. We may even start using the TMJ as a stabilizer!
• Arm Pain
  • It is important to look at how we use our arms. I have a video called Fix Shoulder Pain that looks at arm mechanics.
• Headaches and Migraines
  • My recent blog explores this relationship.
• Nerve Pain
  • Dr. Leslie Russek (The Zebra Club scientific advisor) gave a great explanation of neuropathic pain and managing it

We could also encounter psychological symptoms like anxiety and fear of movement. If you’ve suffered from recurrent shoulder issues, it is totally understandable that shoulder movements could be stressful. We may even tense up in anticipation of the pain.

Strategies to address shoulder hypermobility and take care of our shoulders

There are things we can do to support our shoulders. Here are a few ideas.

• Braces and physical aids
  • Many people find the use of postural t-shirts or devices like the Body Braid helpful in supporting the shoulder joint. They can help with proprioception of where the shoulder should sit.
• Taping
  • Kinesio taping can be an inexpensive way to support the shoulder joint. A recent study on two taping methods (an experimental and a control) found both methods led to significant improvement in patient-reported outcomes after 48 hours in both methods (6)
  • You may have to find a tape that works for you as some people experience allergic reactions to taping. You can also try applying a skin barrier like milk of magnesia before taping.
• Awareness Training
  • My video called The Best Exercises for Shoulder and Arm Pain explores how to build awareness of this area and improve our movement patterns.
• Meditation / Mindfulness
  • There is a growing body of evidence on the benefits of mindfulness and meditation practices on chronic pain. This, together with breathing practices, can help calm the nervous system and reduce sensitization and nociplastic pain
  • We have a growing library of meditations on that are designed specifically for hypermobility and chronic pain on The Zebra Club app
• Work with your providers to find pain relief
  • There are many strategies you can address with your providers. It may help to implement pain relief strategies, like medications, so you can participate in physical and movement therapies (3). Medical interventions like steroid injections, prolotherapy, and surgery may be necessary in certain situations as well.

Recommended exercises for shoulder hypermobility

I always start with breath and relaxation to calm the nervous system and release some guarding patterns from the shoulder joint. Building awareness of how the arm moves in the socket are really helpful to begin with. I like to take a whole-body approach and help people understand how the arms are support from the pelvis.

Local exercises might include scapular stabilization, rotator cuff strengthening, postural alignment, and shoulder stability. But these come after we’ve done the foundational work first.

This quote explains it well: “Much greater energy expenditure is required to maintain shoulder stability in hyperlax individuals. These individuals must train consistently to protect their shoulders from overload” (7). It is hard work to stabilize the shoulders, it takes a lot of energy. If we can improve muscle tone and stability around the shoulders we can reduce this work.

We have a whole collection of classes for shoulder stability in The Zebra Club programs section.

Key preventive tips for shoulder health and injury avoidance

• Alignment & posture
  • If we can get the bones into a better alignment, then the muscular tissue surrounding the joints has a much better chance to start working effectively and providing stability.
• Proprioception and control
  • Working on specific exercises to really sense and understand the movements of the arms and scapular with control can help. Initially, we would want to keep the range of movement small so that we can build our sense of control.
• Stability of the joint
  • We need appropriate local stability exercises for the shoulder. It is important we go low and slow to start. Don’t be tempted to jump in with resistance or weight until you have mastered alignment and control.
  • Gravity is going to be pulling on the shoulder joint constantly throughout the day. The more muscle tone and muscle mass we can build, the more resilient the joint will be against these forces.
• Address ergonomics
  • Many aspects could be impacting the functioning and pain in the shoulder. It is good to examine your desk setup, your driving position, your sleeping position, and your daily activities to see if anything could be contributing to pain.
• Address spinal thoracic stiffness
  • In my experience, many people with hypermobility have quite stiff thoracic spines. This lack of fluidity and bounce in the thorax can lead to shoulder dysfunction and poor movement patterns. Breathwork is a gentle way to start working on softening the thorax and relaxing tight muscles.
    Check out this video on thoracic mobility
• Mobility of scapula
  • Scapula movement is key to stability and sometimes the scapula can get stuck on the back of the ribcage. Learning good scapula movement and control with a movement professional is important.
• Breathing
  • I often see high-up chest breathing using accessory muscles to breathe as opposed to diaphragmatic breathing. Dysfunctional breathing patterns are common in hypermobility, and these can harm our quality of life (Chohan et al 2021). Learning some relaxing breathing techniques can really help with pain reduction. I’ve also observed a reduction in rib subluxations in my clinical practice through breathwork.
    Try any of the breathing classes in The Zebra Club or this one.

Check out this live class I did discussing shoulder stability. I then walk you through a movement practice focusing on this.

FAQs

How rare are double-jointed shoulders?
Double-jointedness is known as joint hypermobility and it is not uncommon. Estimates suggest that anywhere from 10% to 30% of the general population may have some degree of joint hypermobility.

What is the difference between hypermobile and normal shoulders?
The main difference will be the range of motion and stability. Normal shoulders have a healthy balance of flexibility and stability, which allows for a wide range of movement whilst maintaining joint integrity. The muscles, ligaments, and tendons can provide sufficient support. This is not always the case with hypermobile shoulders.

How do you sleep with hypermobile shoulders?
Stabilizing the shoulder joint with more muscle tone can definitely help. I worked with a client who was subluxing the joint every night when she slept, this stopped happening! Pillows and supports can also help you get comfortable.

Literature review / research by Catherine Nation, MSc, PhD

1. Liaghat et al. (2022) Clinical Characteristics of 100 Patients With Hypermobility Spectrum Disorders and Shoulder Complaints With or Without Mechanical Symptoms: A Cross-sectional Study. American Congress of Rehabilitation Medicine. 
2. Chang et al. (2023) Anatomy, Shoulder and Upper Limb, Glenohumeral Joint. NIH NLB StatPearls.
3. Brioda et al (2021) Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome. Journal of Shoulder and Elbow Surgery: Reviews, Reports and Techniques
4. Spanhove et al (2022) Electromyographic Muscle Activity and Three-Dimensional Scapular Kinematics in Patients With Multidirectional Shoulder Instability: A Study in the Hypermobile Type of the Ehlers-Danlos Syndrome and the Hypermobility Spectrum Disorders. Arthritis Care and Research.
5. Johannessen et al (2016). Shoulder function, pain and health related quality of life in adults with joint hypermobility syndrome/Ehlers–Danlos syndrome-hypermobility type. Disability and Rehabilitation. 
6. Tudini et al (2023) Evaluating the effects of two different kinesiology taping techniques on shoulder pain and function in patients with hypermobile Ehlers-Danlos syndrome. Frontiers in Pain Research.
7. Jaggi & Lambers (2010) Ch. 12.1 The Shoulder Joint. Hypermobility, Fibromyalgia and Chronic Pain. Ed. Alan J Hakim, Rosemary J. Keer, Rodney Grahame. Churchill Livingstone Elsevier.