Hypermobility syndrome / Ehlers-Danlos of the hand and wrist

What are Hypermobility Syndrome (HSD) and hEDS?

Hypermobility describes an increased range of motion of one or more joints. Many people are hypermobile without having any symptoms. We speak of a hypermobility spectrum (HSD) when hypermobility is accompanied by typical symptoms such as pain, instability, fatigue or recurring injuries without the criteria of hypermobile Ehlers-Danlos syndrome (hEDS) being met. hEDS is a clinically defined form of Ehlers-Danlos syndrome in which generalized joint hypermobility combines with systemic feature clusters and typical symptoms.

• HSD: Complaints due to hypermobility, without complete hEDS criteria
• hEDS: clinical syndrome with generalized hypermobility and systemic features (diagnosis according to 2017 criteria)
• Other types of EDS (e.g. vascular type) are rare, genetically detectable and require special investigation

In the hand and wrist, HSD/hEDS often lead to recurrent sprains, subluxating joints, thumb and ulnar wrist pain (TFCC region), as well as rapid fatigue during everyday and office work.

Anatomy and stability of the hand

The stability of the hand arises from the interaction of bones, capsular ligaments, tendons/muscles and the sensorimotor system. In hypermobility, the capsule and ligaments in particular are more flexible, which reduces passive stability. The muscles and proprioception then have to compensate more.

• Thumb saddle joint (CMC I): predestined for overload and subluxation
• MCP joints (finger joints): frequent “bending” in extension
• TFCC (triangular fibrocartilaginous complex): key structure for ulnar stability of the wrist
• Carpal ligaments (e.g. scapholunate): sensitive to repeated overstretching

From an orthopedic perspective, the goal is to improve active stability through targeted, pain-sensitive strengthening and coordination and to use passive guidance (e.g. orthoses) in a measured manner.

Typical hand and wrist complaints

• Diffuse wrist pain, often on the ulnar side (TFCC) or in the saddle joint of the thumb
• Feeling of "folding away" or insecurity when gripping/carrying
• Quick tiring, loss of grip strength, morning stiffness
• Cracking/snapping, recurrent sprains or subluxations
• Increased pain with prolonged typing, writing, tool use
• Tendinopathies (e.g. De Quervain-like complaints) through compensation
• Skin sensitivity, tendency to bruise; With EDS, wound healing is sometimes delayed

Symptoms can fluctuate in phases. Stress, lack of sleep, infections or hormonal changes influence resilience.

Causes and risk factors

The basis of HSD/hEDS is increased tissue flexibility - in hEDS probably due to changes in the connective tissue structure. A clear genetic cause has not yet been identified for hEDS (unlike other types of EDS).

• Familial accumulation of hypermobility
• Female gender (hormonal influences)
• Early sporting or occupational overload without adequate stabilization
• Previous injuries with permanent ligament laxity
• Concomitant factors: lack of sleep, stress, deconditioning

Diagnostics: How we proceed

The diagnosis is based on history, physical examination and – if hEDS is suspected – on the 2017 clinical criteria. Imaging is primarily used to detect accompanying structural damage (e.g. TFCC lesion).

Genetic testing is currently not possible for hEDS; however, it may be indicated if other types of EDS are suspected. In our practice, we value a clear discussion of findings and shared therapy goals.

Differential diagnoses of the hand and wrist

• Ligament injuries (e.g. scapholunate instability) after trauma
• TFCC lesion independent of hypermobility
• Early arthroses: thumb saddle joint (rhizarthrosis), midcarpal/radiocarpal
• Inflammatory rheumatic diseases (e.g. rheumatoid arthritis, psoriatic arthritis)
• Compression neuropathies (e.g. carpal tunnel syndrome)
• Ganglions, tendonitis
• Systemic connective tissue diseases (e.g. Marfan syndrome) – rare

Conservative therapy: stability before immobility

The goal is to achieve a resilient balance of stability, mobility and pain reduction. The core is structured hand therapy, supplemented by everyday adjustments and dosed aids. Immobilization is only used for a short time and in a targeted manner.

• Education & goal setting: realistic expectations, self-management
• Hand therapy: sensorimotor training, coordination, targeted strength of the thenar/interosseous muscles
• Proprioceptive practice: low load, high repetition, pain-guided
• Orthoses: CMC-I orthosis (thumb) during stress phases, flexible wrist bandage during activities; customized
• Taping: short-term support for proprioceptive feedback
• Workplace adaptation: ergonomic mouse/keyboard, pen aids, micro-breaks
• Load control: staggering activities, pacing, changing grip types
• General Fitness: Core/shoulder girdle stability improves hand control
• Skin and scar care (for EDS): gentle, low-friction

Locally effective measures (e.g. topical NSAIDs) can be used. Oral painkillers should be used in low doses and for a limited period of time. Non-drug procedures such as heat/cold, TENS or relaxation procedures can have a supportive effect.

Injections and regenerative options: with a sense of proportion

If there are localized areas of pain or inflammation, targeted infiltration can be considered. With HSD/hEDS, restraint is required as tissue can be more fragile and overstretching cannot be corrected through injections.

• Corticosteroid injections: rare and strictly indicated, preferably ultrasound-targeted; Be aware of the risk of tissue atrophy
• Hyaluronic acid in the thumb saddle joint: can reduce pain in individual cases; Evidence heterogeneous
• PRP/ACP: not proven for generalized laxity; May be discussed as a supplement in the case of circumscribed tendinopathies
• Local anesthetic test infiltrations: for diagnosing specific sources of pain

We clarify opportunities and limitations transparently in advance and only incorporate such procedures into an overall concept with active therapy and everyday adjustments.

Surgical options: rare and individual

Operations are the exception for HSD/hEDS and are only considered if there is a clear structural cause and failure of consistent conservative measures. The risk of complications (wound healing, recurrences) is increased; careful planning is essential.

• Stabilizing interventions: capsuloligamentous tightening, tendon transfers/reconstructions
• TFCC repair or augmentation for proven lesions with correlating symptoms
• Arthrodesis in selected cases of advanced instability arthrosis
• Specifics of EDS: gentle tissue guidance, adequate suture material, bleeding/skin management

Whether an operation makes sense is decided in the individual context. We discuss alternatives and the realistic results that can be expected - without any promise of cure.

Everyday life and sport: practical tips

• Enlarge handles: thicker pens, ergonomic kitchen utensils
• Carry loads close to your body, carrying techniques vary
• Microbreaks with short proprioceptive exercises (e.g. isometric holds)
• Prefer sports with controlled movements (e.g. swimming, cycling, quiet strength training).
• Avoid explosive, wide end positions; Stabilize movements “in the middle”.
• Use safety orthoses for a limited period of time during peaks (moving, longer gardening).
• Sleep hygiene and stress management for pain modulation

Course and prognosis

The process is individual. Many affected people achieve a significant improvement in function and fewer pain peaks with information, adapted activity and targeted hand therapy. The goal is not maximum mobility, but rather controlled, pain-free stability in everyday life. Setbacks are possible, but can often be overcome with tried and tested self-management.

Warning signs: when should you seek medical advice?

• Acute misalignment/blockage (dislocation) or significant deformity
• Numbness, tingling or persistent loss of strength
• Ulnar-side wrist pain after trauma with painful rotation
• Unusually severe hematomas, poor wound healing
• Coldness, paleness or discoloration of the fingers (circulatory problems)

In the case of such signs, we ask that you introduce us as soon as possible. In an emergency, please contact the emergency services.

Your treatment in Hamburg-Winterhude

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we analyze symptoms and everyday situations in a structured manner. We prioritize conservative measures, coordinate hand therapy if necessary and tailor orthotic care individually. We take interdisciplinary aspects (e.g. skin, pain psychology) into account as required.

We work in an evidence-conscious and open-ended manner. We don't give a promise of healing - instead we offer a clear, collaborative treatment approach.