Understanding double-jointed elbows

“Double-jointed” elbows may be just a hypermobile joint or a symptom of a more widespread connective tissue disorder like hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD). In fact, the ability to hyperextend elbows beyond 10 degrees past the normal range is included in the Beighton criteria a part of the current diagnostic criteria for hEDS, though this is not a requirement for diagnosis (1).

When only one joint is hypermobile this may be known as localized joint hypermobility or LJH. This happens when a single joint (can be on both sides) or group of joints is hypermobile. This can be classified as a subtype of Hypermobility spectrum disorder (HSD) – Localized HSD or L-HSD when a person has localized hypermobility and one or more secondary musculoskeletal manifestations including chronic pain, altered proprioception, and trauma such as dislocations or subluxations among others (2).

It is also important to remember that hypermobility does not necessarily mean instability.

The anatomy of the elbow

The elbow is a complex hinge joint where the humerus (upper arm bone) meets with the two bones of the lower arm, the radius and ulna. Together these form a hinge joint that along with the muscles and ligaments (MCL & LCL) and nerves, can flex, extend, pronate, and supinate. The ligaments in the elbow lend stability and are in constant tension through the joint’s movement, making them injury-prone (3). Muscles that surround the elbow are biceps brachii, triceps brachii, brachialis, brachiordialis, and forearm flexors and extensors.  The nerves are the ulnar, radial, and median nerve.

 Exploring research on hypermobility in elbows

There is not very much research specifically on hypermobile elbows themselves.

Hypermobility may be related to more soft tissue issues in small joints – including elbows

• In the 90s a rheumatology clinic reported an association between soft tissue rheumatism (including tendinitis, bursitis, fasciitis, and regional pain syndromes) and hypermobility at the small joints – including elbows. The hypermobile patients also reported more recurring episodes than non-hypermobile patients (4).

A small percentage of patients report elbow dislocations and even fewer report sprains

• An analysis of EDS characteristics was done at two Italian treatment centers. Patients were included if they had joint hypermobility syndrome EDS hypermobility type (now hEDS) or both. An average of 7.5% reported elbow dislocations, and about 1% reported elbow sprains (5).

Elbow range of motion is different during walking in hypermobile adolescent girls

• Another small study used kinematics to look at how arms moved while walking in a group of girls aged 12 – 15. Kinematic instrumental gate analysis assesses movement patterns and the angles of the joints as a person walks. They found the hypermobile group had significantly more flexion or bending of the forearm in the forward swing phase and a significant decrease in the backward swing phase (6)

Issues with the elbows

I’ve experienced two episodes of elbow issues – one tennis elbow and one golfer’s elbow.  Both of these are types of tendonitis affecting the elbows, but they differ in their location and the tendons involved.

Golfer’s elbow or Medial Epicondylitis in pain on the inside of the elbow and involves tendons that attach to the medial epicondyle of the humerus or upper arm bone.  It affects the flexor muscles of the forearm.  I developed Golfers Elbow after just ONE golf lesson for an hour!   That’s how sensitive our tissues can be.  I was doing a repetitive putting motion for almost an hour and that was enough to cause the inflammation.  Top tip – avoid repetitive movements if you are hypermobile.

Tennis Elbow or Lateral Epicondylitis is pain on the outside or lateral side of the elbow.  It involves tendons that attach to the lateral epicondyle of the humerus and mostly impacts the extensor muscles of the forearm. I developed this after a number of tennis sessions in my pre-hypermobile aware life when I was not aware of joint control, range of movement, or shoulder stability. I was a beginner using a tennis racket that was probably too heavy for me and due to lack of control and awareness, I would lock my elbow every time I hit the ball. I had both force and poor mechanics which led to inflammation of my tissues.

Both these soft tissue injuries took many months to resolve so if you are also struggling with one of these elbow conditions, be patient with it. Rest, ice, braces and physical therapy or movement therapy can help.

Always see a physical therapist for help diagnosing elbow pain. These are just two common elbow conditions but there are others including

• Elbow Bursitis – inflammation of the bursa
• Cubital Tunnel Syndrome – compression or irritation of the ulnar nerve as it passes through the cubital tunnel on the inside of the elbow
• Radial Tunnel Syndrome – compression of the radial nerve in the forearm
• Distal Biceps Tendon Rupture – a tear of the tendon that attaches the biceps muscle to the radius in the forearm
• Elbow Osteoarthritis – degeneration of the cartilage in the elbow joint

Why we may not want to hyperextend our hypermobile elbows

When we have hypermobile elbows and haven’t learned to control them we can often hyperextend and lock them out when we exercise. I am not a fan of locking elbows for these reasons.

1. When we lock out our elbows, the muscles around the joint no longer have to work, making the joint vulnerable to strain and pain. The muscles are held in a fixed position of neither lengthening nor shortening causing faulty biomechanics.
2. You turn off your powerhouse of muscles by blocking communication to the torso. The arms feed into the back but with a locked elbow this communication is blocked.
3. This can lead to the shoulders being placed out of alignment, which may also cause neck pain.
4. With locking elbows in four-point kneeling, the lumbar spine can collapse, causing strain.
5. It makes any weight-bearing activity very difficult and unstable.
6. In a plank pose, a locked elbow may lead to the wrists being compromised too, as too much weight is now dropping down into the ground.

My recent YouTube video on Exercise Modifications  demonstrates this issue in practice and I explain that organization of the shoulder girdle in weight bearing is where we need to start. It is very hard to simply tell someone to unlock their elbows when for that individual, the locking elbow is their stability. I call this false stability because the joint is very vulnerable in that position.

 Strategies for hypermobility elbow discomfort with exercise

There are lots of reasons to learn how NOT to lock those elbows. I’m not saying this will be easy because you may have done it your whole life without even realizing it. This can become a subconscious habit that you need to retrain. This takes patience and practice. How do we do it?

• There are many ways, but I would start with non-weight bearing activity and learn correct arm and shoulder mechanics.
• We can improve proprioception so we become aware when we do this – If you’re not aware you do something, you will have no idea how to change it. Once you become aware, change can happen.
• Build strength in the upper back. The elbows lock because they are trying to stabilise you either out of habit, lack of awareness or lack of trust that the back muscles are going to do the job.
• I have a YouTube video called Tips for Hypermobile Elbows (see below) that will be useful in understanding how to weight bear without locking the elbow joints.
• Much of what I do in the clinic and in The Zebra Club is teaching people how to use their arms correctly. This is retraining the nervous system on how to move without locking elbows automatically. My video called Fix Shoulder Pain in Hypermobility can help you get started on this process.
• Ensuring proper techniques – avoid what I did in my tennis lessons! Correct form will help avoid strain.
• Strengthening exercises for the forearm and upper arm muscles can help protect the elbow joint.
• Ergonomic adjustments at work can help ensure reduction in repetitive strain injuries.

All of this can be learnt through appropriate movement practices designed for our hypermobile bodies. Remember, just because we can, doesn’t mean we should. I can lock my elbows but I’m always trying my absolute hardest not to. It does take practice, but the fact that you become aware that you do it, is the first step towards making a change.

Watch this video for some tips for working with hypermobile elbows.

Literature Review and Research by Catherine Nation MSc, PhD

1. Malfait et al (2017) The The 2017 International Classification of the Ehlers–Danlos Syndromes. American Journal of Medical Genetics Part C (Seminars in Medical Genetics).
2. Carroll, Matthew B (2023). Hypermobility spectrum disorders: a review. Rheumatology and Immunology Research.
3. Downing & Sergent (2023) Anatomy, Shoulder and Upper limb, Elbow collateral ligaments. National Library of Medicine StatPearls.
4. Hudson et al (1998) The association of soft-tissue rheumatism and hypermobility. British Journal of Rheumatology.
5. Morlino et al (2017) Refining Patterns of Joint Hypermobility, Habitus, and Orthopedic Traits in Joint Hypermobility Syndrome and Ehlers–Danlos Syndrome, Hypermobility Type. Medical Genetics.
6. Vorontcova et al (2019) Kinematic instrumental analysis of the shoulder and elbow joint in normal conditions and with hypermobility of the joint in the gait cycle. Pediactric Traumatology, Orthopaedics and Reconstructive Surgery.