Why Are People With Hypermobility So Tired? Fatigue in hEDS and HSD
Fatigue is common in hEDS and HSD and usually has several sources at once. What studies found on joint work, pain and sleep, standing, and ME/CFS.
Photo: James Forbes / Unsplash
Fatigue is one of the most common symptoms of hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD), and it usually has more than one source. Holding loose joints steady can take extra muscle work, pain can break up sleep, and standing up can make the tiredness worse. In a 2026 meta-analysis, about half of people with hEDS or HSD reported chronic fatigue. That kind of study, a meta-analysis, combines the results of several studies into a single figure. The studies below suggest your tiredness and your joints can be connected.
hEDS and HSD: what each label means
The studies below use both labels, so here is how they differ. The Ehlers-Danlos syndromes are inherited connective tissue disorders. Skin, ligaments, and blood vessels all get their strength and stretch from connective tissue. In 2017, Fransiska Malfait and an international consortium of EDS experts revised the clinical criteria for hEDS so clinicians could tell it apart from other joint hypermobility disorders. In the introduction to their 2026 meta-analysis, Dmitrii Kulin and colleagues explain that clinicians diagnose HSD when someone has symptoms from joint hypermobility but doesn't meet those criteria.
The Beighton score is the usual starting point, a 9-point check of the pinkies, thumbs, elbows, knees, and spine. I'm hypermobile myself and score 7 out of 9, yet most of my symptoms are in my fingers, in small joints the score barely counts. That is why clinicians make the diagnosis from the full criteria and an exam, not the Beighton score alone.
How common is fatigue in hEDS and HSD?
Kulin's team pooled 19 studies of 17,455 people with hEDS or HSD, mainly about gut symptoms. In their results, chronic fatigue was the most common condition outside the gut, at 49% across five studies, so about half. The authors rated the quality of the evidence as low. The studies differed a lot, and they used several sets of diagnostic criteria.
A 2025 survey from the University at Buffalo looked more closely at one group. Meagan Collins Hutchinson, Svetlana Blitshteyn, and colleagues surveyed 84 women with physician-diagnosed HSD or hEDS. Nearly all of them (98.8%) reported chronic pain, and 26.2%, about one in four, reported a diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
Why holding loose joints steady can be tiring
The first source is the joints themselves. When ligaments are loose, muscles usually do more of the work of keeping joints stable. Hypermobile people can also lock a joint to stabilize it, since locking takes less effort in the moment than engaging the muscles around it.
Nicol Voermans and colleagues at Radboud University compared muscle strength and fatigue in 30 people with EDS recruited through the Dutch patient association. Fatigue was more severe in people with weaker muscles, whether the researchers tested strength by hand or with a handheld dynamometer, or asked people to rate it themselves. A dynamometer is a device that measures how hard a muscle can push. Muscle weakness and pain severity both predicted fatigue severity, and the authors wrote that the results suggest a direct relationship. It was a small study from 2011, before the 2017 criteria, so it isn't clear how well this applies to hEDS today.
This is one reason I think physical therapy with someone who knows hypermobility is so useful. People with hypermobility are good at bypassing the muscle an exercise is meant to train. It can help to work with a PT who can tell you where you should feel it, in your glutes rather than your thighs, for example. Injuries and the time off after them can add a loss of fitness on top.
Pain and broken sleep
Pain is the second source, possibly in part through what it does to sleep. In 2010, Voermans's team surveyed 273 members of the Dutch EDS patient organization. Chronic pain was highly prevalent, and it was more common and more severe in the hypermobility type than in the classic type. People with more pain had poorer sleep at night. Pain also added to impairment in daily life independent of how fatigued people were, so pain adds its own share of the load, over and above fatigue.
Standing up: POTS and orthostatic intolerance
Standing is the third source. Orthostatic intolerance means symptoms that come on with standing and get better once you're lying flat. Kulin's team found it in 35.9% of people with hEDS or HSD, a bit over a third. Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance in which the heart rate rises sharply on standing. Their pooled POTS figure was 21.9%, about one in five, from three studies with a wide range around it. In the Buffalo survey of women, 58.3% reported a POTS diagnosis, more than half, so the estimate depends on which group the researchers studied.
Being upright can also lower the blood supply to the brain. In a 2020 Dutch study, Linda van Campen and colleagues measured brain blood flow in 429 adults with ME/CFS during a tilt-table test, which tilts a person from lying flat to 70 degrees. At the final measurement, their brain blood flow was down 26%, about a quarter, against 7% in healthy controls. Even among people whose pulse and blood pressure stayed in the normal range, 82%, about four in five, had a drop beyond the healthy controls' normal range. That study was in ME/CFS rather than hEDS, but it suggests how being upright can bring on symptoms even when the usual tilt numbers look normal. I cover POTS within ME/CFS separately.
POTS in hypermobility can come with other diagnoses too. A quarter of the Buffalo women reported hEDS or HSD, POTS, and mast cell activation syndrome (MCAS) together. I think of the three as a triad, since they can make each other worse, although researchers still debate how common MCAS is in POTS and hEDS.
Is it hEDS fatigue or ME/CFS?
With a quarter of the Buffalo group reporting ME/CFS, the next question is how to tell hEDS fatigue from ME/CFS. Post-exertional malaise (PEM) is the main difference. PEM is a crash in symptoms after effort of any kind, physical, mental, or emotional, and the crash is far bigger than the effort itself. It can be delayed by a day or longer. Tiredness from joint work, pain, or standing usually eases with rest, whereas PEM can last for days. Both conditions can be present at once, and no study so far has shown that hEDS causes ME/CFS. I explain what post-exertional malaise looks like in its own post.
Sorting out your own fatigue with a clinician
For an appointment about fatigue with hypermobility, I'd bring:
- Your joint history: which joints are loose, any dislocations or injuries, and who diagnosed your hEDS or HSD, using which criteria.
- Whether you feel worse after standing in a line or showering and better lying down.
- How you sleep, how many times a night pain wakes you, and whether you wake up refreshed.
- How you feel a day or two after a busier day, which helps sort out PEM.
- Which rule-outs you've already had, such as iron and ferritin, thyroid, and B12.
My course Hypermobility, Reconsidered opens Friday, November 20, and the chronic fatigue hub has my other fatigue posts.
If chronic fatigue is part of your picture, ME/CFS, Reconsidered is an upcoming course on ME/CFS, post-viral fatigue, and pacing. You can join The Weekly Well, our free newsletter, to hear when the course opens.
FAQ
Is fatigue part of hEDS and HSD?
It is one of the most common symptoms. In a 2026 meta-analysis that pooled five studies, 49% of people with hEDS or HSD reported chronic fatigue, about half. The authors rated the evidence as low quality, because the included studies differed a lot from one another.
Why do my muscles tire so easily with hypermobility?
When ligaments are loose, muscles usually do more of the work of keeping joints stable. In a small 2011 Dutch study of 30 people with EDS, fatigue was more severe in people with weaker muscles, and muscle weakness and pain both predicted how tired people were.
Is POTS common in people with hypermobility?
It can be. A 2026 meta-analysis put POTS at 21.9% of people with hEDS or HSD, about one in five, based on three studies with a wide range around the estimate. In a 2025 survey of 84 women with hEDS or HSD, 58.3% reported a POTS diagnosis, more than half.
How can I tell hEDS fatigue apart from ME/CFS?
Post-exertional malaise (PEM) is the main difference. PEM is a crash in symptoms after effort, much bigger than the effort itself, and it can be delayed by a day or longer. Both conditions can be present at once, and about one in four women in a 2025 hEDS and HSD survey also had an ME/CFS diagnosis.
Does a high Beighton score mean I have hEDS?
No. The Beighton score is one part of the clinical criteria for hEDS, and the 2017 international classification revised those criteria so clinicians could tell hEDS apart from other joint hypermobility disorders. Clinicians diagnose hypermobility spectrum disorder instead when someone has symptoms from joint hypermobility but falls short of the full hEDS criteria.
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