Hypermobility syndrome / Ehlers-Danlos of the hand and wrist

Important notice

This page is provided for medical information only. Gesundheitszentrum Prof. Dr. med. Citak does not provide treatment for hypermobility spectrum disorder (HSD) or Ehlers-Danlos syndrome (EDS). If you suspect or have a confirmed diagnosis, please contact a medical or interdisciplinary service that specialises in these conditions.

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: general principles

Diagnosis is based on medical history, physical examination and, if hEDS is suspected, the 2017 clinical criteria. Imaging is mainly used to identify associated structural changes, such as a TFCC lesion. Individual assessment should be carried out by an appropriately specialised service.

There is currently no genetic test for hEDS; however, testing may be indicated if other types of EDS are suspected.

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

The benefits and limitations of such procedures should always be assessed by a specialist as part of an overall plan that includes 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 surgery is appropriate should be decided by a specialist in the individual context. Alternatives and realistic outcomes should be discussed carefully.

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)

If these signs occur, seek prompt assessment from an appropriate medical service. In an emergency, contact the emergency services.

Appropriate specialist services

HSD and EDS often benefit from interdisciplinary care, for example through specialised clinical genetics, rheumatology, pain medicine, physiotherapy or occupational therapy, and other disciplines where needed. The appropriate service depends on the diagnosis, symptoms and possible associated conditions.