Management of Joint Instability: acute and long term

Why do dislocations or subluxations happen when you're hypermobile?

The primary cause is an abnormal collagen composition. Collagen — mainly Type 1 — is the key structural protein in the body’s connective tissues. It is present in ligaments, tendons, and joint capsules, giving them strength and stability.

• Ligaments connect bone to bone

• Tendons connect muscle to bone

• Joint capsules are tissue envelopes surrounding synovial (moveable) joints

All of these structures tighten under tension, preventing the bones forming a joint from moving too far apart. In this way, ligaments, tendons, and joint capsules are crucial for joint stability.

In hypermobile Ehlers-Danlos Syndrome (hEDS, 2017 International Classification) — formerly EDS hypermobile type or Type III — the connective tissues are inherently more lax due to the genetic disorder. This increased stretchiness of ligaments and tendons reduces joint stability, making joints more prone to subluxations and dislocations.

Both dislocations and subluxations involve a shift in the position of the bones — the difference is how far they move:

• Dislocation: Bones no longer make contact at all (complete separation)

• Subluxation: Partial displacement in which the bones are still touching, but misaligned

  
  

Although subluxations often resolve on their own or can be reduced at home, they can be just as painful as dislocations. Dislocations usually require medical or physiotherapy input to ensure proper reduction without damaging nearby structures.

In people with hEDS and HSD, these episodes occur more frequently due to altered connective tissue, but are also influenced by:

• Altered muscle tone and weakness which affect ability for a muscle to switch on

• Impaired proprioception, coordination, joint position sense

• Repeated or excessive stretching

• Shallow-shaped joint sockets or other bony shaped anomalies that predispose a joint to slipping out of position more easily

As physios, we need to first:

• Understand direction of instability, is it multidirectional or not?

• Investigate the underlying cause of the instability. Hypomobility/stiffness above or below an area can cause more hypermobility in a given joint. Weakness or maladaptive movement patterns can also contribute to subluxations

• Advice about how to prevent or manage acute subluxations through exercise, modalities, braces

Hypermobility does not mean instabiity. We can help treat unstable joints and stabilize hypermobile joints before they become unstable.

Acute Management

• Breathe – Take slow, deep breaths. Use relaxation techniques to reduce stress and regain control.

• Analgesia – Take pain medication as prescribed. Do not exceed the recommended dose; even partial relief is helpful.

• Support the joint – Use pillows or a sling to find a comfortable position. This helps muscles relax and reduces spasm.

• Heat – Apply a hot water bottle, wheat bag, or take a warm bath to ease muscle spasm.

• Distraction – Focus on music, film, conversation, or relaxation audio to reduce pain perception and encourage relaxation.

• Gentle massage – Light massage around the joint can relax surrounding muscles, helping the joint to relocate naturally.

When to Seek Emergency Care

Go to the ER immediately if any of the following are present:

Signs of fracture or significant tissue damage

• Visible deformity that does not resolve after attempted reduction

• Open wound or exposed bone

• Rapid swelling or bruising

• Audible crack or pop at the time of injury followed by intense pain

Neurological symptoms

• Numbness, tingling, or “pins and needles” below the joint

• Loss of sensation

• Weakness or inability to move the distal limb

• Loss of motor control or coordination

Vascular compromise

• Coldness or pale/bluish color of the limb

• Absent or weak pulse below the joint

• Capillary refill greater than 3 seconds

Instability or inability to use the limb

• Joint is “locked” and cannot move through the normal range

• Cannot bear weight or use the limb

• Joint repeatedly dislocates immediately after reduction

Severe or uncontrolled pain

• Pain does not settle within 20–30 minutes even after reduction, immobilization, and basic analgesics

• Pain is worsening instead of improving

Other concerning features

• Suspected head/neck trauma (e.g., dizziness, blurred vision, headache, severe fall, direct blow, loss of consciousness)

• Shortness of breath, chest pain, nausea, or fainting

• Uncertainty about whether the joint relocated correctly or if it keeps slipping out

When It’s Generally Safe to Manage at Home or Through Urgent Care

• The joint subluxed but self-reduced quickly

• No neurological or vascular symptoms

• Pain is mild or moderate and improving

• No deformity, fracture signs, or loss of function

• Able to move and bear weight comfortably after the episode

Reference

https://www.ehlers-danlos.com/dislocation-subluxation-management/