Pilates guide
If your joints bend further than most, Pilates can be a good way to build the strength and control that protect them. The NHS lists it among lower-risk activities for Ehlers-Danlos syndromes (EDS), and the Hypermobility Syndromes Association (HMSA) suggests Pilates focused on strength and control rather than flexibility. The catch is that many Pilates moves are built around reaching and stretching, which isn't what bendy joints need more of.
The research is still thin. One large online trial of a Pilates programme designed for hypermobility found modest improvements, but it wasn't randomised and many people dropped out; a randomised trial is now recruiting. This guide covers what hypermobility spectrum disorder (HSD) and hypermobile EDS (hEDS) mean, what the evidence shows, how a class should be adapted, which moves to change or leave out, Pilates with postural tachycardia syndrome (PoTS) and fatigue, reformer and hot classes, and when to get help. It ends with a free 20-minute supported class.
The NHS lists Pilates among lower-risk activities with EDS. The HMSA says yoga, Pilates and tai chi focused on strength and control rather than flexibility are worth trying, and PoTS UK notes Pilates can be done lying down.
The NHS says the main treatment is improving muscle strength and fitness, and not to overextend your joints just because you can. The Ehlers-Danlos Society warns that overstretching "may lead to instability".
In the one sizeable trial, an online programme designed for hypermobility gave modest improvements, slightly below the change people usually notice. It wasn't randomised, many people dropped out and the programme's owner was a co-author. A randomised pilot trial is recruiting.
Start in supported positions, change position less often and slowly, work in the middle of your range, keep elbows and knees soft, use fists or forearms for your wrists, and keep breathing. Start with about 20 minutes and notice how you feel over the next 48 hours. This is expert advice, not tested rules.
Do the lying moves first, sit for a minute before standing, drink two glasses of water beforehand, keep cool and cool down gradually. Avoid heated classes: getting too hot can trigger symptoms.
Fainting while exercising means call 999. A joint that has come out and stayed out needs A&E. Sore muscles for a few days are normal; sharp joint pain or a joint slipping are not.
Our hypermobility exercise guide covers these in more depth.
Joint hypermobility means joints that move further than usual. You can be born with it or develop it through training, illness or injury, and the Ehlers-Danlos Society says being flexible, bendy or double-jointed "is not usually a problem". How common it is depends on the definition: around 1 in 30 people (NHS), around 1 in 10 (HMSA) or up to about 20% (Ehlers-Danlos Society). In one UK survey, 18.3% of 12,853 adults were hypermobile. A diagnosis is much rarer: in Wales, about 194 in every 100,000 people had a recorded diagnosis of EDS or joint hypermobility syndrome, 70% of them women.
HSD is hypermobility that causes symptoms, such as pain, sprains or joints that slip out, when no other condition explains it. hEDS is the most common of the 13 types of EDS. It is diagnosed from your history and an examination against criteria set in 2017, and there's no genetic test for it. The NHS says HSD "is treated in the same way as hEDS". The 2017 framework replaced the older name joint hypermobility syndrome, which one NHS page still uses.
A 9-point check of the little fingers, thumbs, elbows, knees and spine. A score of 5 or more suggests generalised hypermobility in adults (6 or more before puberty, 4 or more over 50). A 5-question self-check, positive with 2 or more yes answers, picked up 85% of people with generalised hypermobility and correctly ruled out 90% of those without. Both are screening checks, not a diagnosis.
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Looser connective tissue means muscles have to work harder to hold joints steady. People with hypermobility also tend to have a poorer sense of where their legs are, and some have pain sensitivity, fatigue, low blood pressure, a fast heart rate, gut or bladder problems, or anxiety. The HMSA says symptoms often start "after something changes that tips the hypermobile body from 'can cope' to 'can't cope'", such as an injury, illness, stress or pregnancy.
For joint hypermobility syndrome, the NHS says "The main treatment is improving muscle strength and fitness so your joints are better protected", and "do not overextend your joints just because you can". With EDS, "lower-risk activities, such as swimming or pilates, may be recommended", and it's "important not to be overprotective". For PoTS it suggests "gentle exercise, such as walking, pilates and swimming".
The HMSA lists Pilates among ways to exercise and notes that "Any movement that is completed with control can be a form of exercise". Its physiotherapist-written advice says yoga "(focused on strengthening and control rather than increasing flexibility)", Pilates exercises and tai chi "are worth trying", and recommends static (isometric) strengthening, balance work and keeping joints in their neutral range.
It recommends exercises "that focus on movement control and strengthening the stabilizing muscles", with "a low load on the joint", and to "start low" and "go slow". Its plain-language summary of the 2017 international physiotherapy guideline calls exercise the cornerstone of treatment, graded to avoid flare-ups.
PoTS UK says Pilates "Can provide full body strengthening", and "Exercises can be done laying down as these types of exercises are often ground based or done on a reformer Pilates machine".
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In a UK survey of 946 members of two hypermobility charities, swimming (28%), walking (24%) and Pilates (22%) were the kinds of exercise most often rated helpful. In the full paper from the same survey, people who'd had exercise advice from a physiotherapist were more likely to exercise a lot, and pain, fatigue and fear got in the way.
In an online trial, 420 adults with symptomatic hypermobility were analysed: 200 did a Pilates programme designed for hypermobility (five videos of about 25 minutes, at least 3 times a week for 8 weeks) and 220 waited. On a questionnaire measuring the impact of hypermobility on daily life, scores improved by 25.4 points with Pilates against 1.3 points on the waiting list, slightly below the 30 points proposed as a change people would notice. Body awareness improved. Fear of movement didn't clearly differ between the groups, and activity levels didn't change. Gains held at 6 months, by which time there was no comparison group.
Its limits, plainly: it wasn't randomised (the first people to sign up started straight away and later ones waited) and nobody was blinded. Drop-out was high: about a third of those who signed up never set up an account, and nearly a fifth more didn't finish a single video. The programme's creator and owner was a co-author, though not involved in collecting or analysing the data. And the summary says fear of movement improved compared with the waiting list, while the paper's own table shows no clear difference.
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Of 251 people who filled in the 8-week survey, 17.1% reported some increase in pain or a flare they put down to the Pilates, such as shoulder, wrist, neck or hip discomfort in particular moves. About half said it passed, or settled when they changed or skipped exercises. None was known to be serious.
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People in the same online programme said that exercises designed for hypermobility, feeling safe, a knowledgeable instructor and convenience helped them take part, while fear of injury, pain, fatigue and other illness got in the way. A study of 3 children aged 8 to 12 found less fatigue in two, with no change in pain. A randomised pilot trial began recruiting in July 2026: about 100 adults with hEDS or HSD, weekly in-person Pilates for 6 weeks against weekly education sessions, due to finish around December 2027.
Reviews agree that people improve over time with exercise, but controlled trials are few and small (one review found 6 randomised trials, of 20 to 57 people each), and one review called the evidence that treatment beats a comparison "weak". Across 10 studies of 330 people with EDS or HSD, all showed some improvement, with one minor side effect reported. In 38 women, 8 weeks of trunk stabilisation exercise 3 times a week eased pain and improved trunk endurance and balance more than no exercise. In 100 adults with hypermobile shoulders, heavier, full-range strengthening did a little better than light exercise at 16 weeks, with more short-lived soreness, no serious harms and no clear difference at a year.
Across 5 studies (254 people), people with hypermobility had a poorer sense of joint position in the legs. In 18 people, 8 weeks of exercise with the feet on the ground (closed-chain exercise) improved knee joint sense and pain, and in another small study joint-sense training eased pain compared with no exercise.
In 42 healthy pregnant women, 8 weeks of Pilates kept knee ligament looseness and Beighton scores steady while they rose in women who didn't exercise, and the difference lasted to 6 weeks after birth in those who kept going. That's the normal loosening of pregnancy, not a hypermobility disorder.
The Pilates Association Australia (PAA) published these recommendations for teachers working with EDS or HSD, written by a physiotherapist who teaches Pilates. They're expert advice, not tested rules.
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The programme in the trial cut down the number of position changes, avoided breathing patterns that tense the core too much, slowed the movements down, started exercises in positions with more support, and added cues for common mistakes and more sensory cues.
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An editorial by Pilates teachers who work with hypermobility notes that "Breath-holding is a significant factor in hypermobility" and that "Feedback is key": hands-on cues, your own hands on the area, and small props such as a soft ball or cushion help you feel what you're doing. In their case report, the client sat for a minute or so between lying on their back and kneeling, to avoid dizziness.
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In 32 people with generalised hypermobility, focusing on a target outside the body rather than on the body part improved balance in one crossover study. In class, a cue such as "push the ball away" rather than "tighten your thigh" is that idea (our example).
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The HMSA, Pilates teachers and the Ehlers-Danlos Society all advise working in the middle of your range and not resting joints at the end of it. The two trials that tested range found no harm from going further: in 26 children with knee pain, exercising into the hypermobile range eased pain as much as stopping at neutral, with no adverse events, and in 100 adults, heavier full-range shoulder training was safe and a little better in the short term.
So treat mid-range control as a sensible starting point and the experts' consensus, not a proven rule. Range and load can grow with your physiotherapist's guidance.
The online trial asked for about 25 minutes at least 3 times a week, and people managed 2.3 sessions a week on average. Our editorial starting point: about 20 minutes, 2 or 3 times a week, alongside the strength routine from our hypermobility exercise guide. Start low and go slow, as the Ehlers-Danlos Society puts it, and adjust the next session to how you felt over the following 48 hours.
The NHS says not to do repetitive exercises or activities, and to take regular breaks (pacing); people with EDS can be taught ways to conserve energy and pace their activities. The HMSA suggests staying at one task or in one position for no more than half an hour.
No trial has tested individual Pilates moves in hypermobility. These changes are our reading of expert advice from the sources below, and the two trials that tested range found no harm from going further, so treat them as a sensible start, not rules for life.
The saw, spine stretch forward, mermaid, single and double straight leg stretches, and the full roll-up: keep each reach short of the end of your range and hold the bendy part still. Expert advice: "Overstretching beyond the normal range of motion can be harmful" (Ehlers-Danlos Society), "do not overextend your joints just because you can" (NHS), and don't sit "with any joints resting at the end of their range" (HMSA).
The roll-over, jack knife, control balance and boomerang put weight on your neck and upper back. Our suggestion is to leave them out unless a physiotherapist who knows your neck has cleared them, and to keep rolling moves such as rolling like a ball and the seal small, if you do them at all.
No trial has tested these moves. The Ehlers-Danlos Society says forceful neck and spine manipulation is unsafe with EDS and HSD because of risks including damage to arteries, stroke and spinal fluid leaks, and one case report describes a spinal fluid leak after a "pop" in the neck during a reformer class, in a woman without a connective tissue disease. Such leaks are associated with connective tissue disorders.
The knee hover, leg pull front, push-up, side bend, leg pull back and crab: use fists or forearms, keep your elbows soft rather than locked, and push the floor away rather than sinking into your shoulders. Start with the knee or forearm versions. Wrist and shoulder discomfort were among the problems people reported in the online trial.
The single leg circle, side leg circles and side kick: keep circles and swings small and your pelvis still, working the mid and inner range before the outer range, as the PAA advises.
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The full swan dive, double leg kick and rocking: keep the back bend small and controlled.
In standing work, planks and push-ups, keep your knees and elbows soft, never pushed back as far as they go.
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Breathe out on the effort and let your tummy work without gripping.
Reformer jumpboard work is high impact. The Ehlers-Danlos Society advises people with unstable joints to avoid "high-impact activities (such as running and jumping)".
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In PoTS, your heart rate goes up after you get up from sitting or lying down, often making you feel dizzy or light-headed. The NHS says it's more likely with joint hypermobility syndrome. Triggers include getting too hot, standing or sitting upright for long periods, eating, not drinking enough, alcohol, resting too much, exercise and periods.
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In the UK charity survey of 946 people, 41% reported problems with the nervous system's control of heart rate and blood pressure. At a UK fainting clinic, 82% of 218 hypermobile patients had an abnormal tilt-table test.
PoTS UK's exercise advice, which agrees with our PoTS exercise guide:
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Most mat Pilates is done lying, side-lying or kneeling, which suits the lying-first order PoTS UK suggests, as long as you change position slowly. Do all the lying moves, then all the side-lying ones, then kneeling, then sitting and standing, and sit for a minute before you stand (our suggestion, from the sources here).
In 19 people with PoTS, 3 months of exercise training improved quality of life where a beta blocker didn't. Experts advise starting with exercise lying or sitting down, such as rowing, swimming or a recumbent bike, and most of 7 studies in one review found aerobic training improved symptoms. Another review found only one study that reported on people with EDS, so evidence in hypermobile people specifically is scarce.
If you also have myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), PoTS UK notes that the National Institute for Health and Care Excellence (NICE) recommends any physical activity be overseen by an exercise specialist in an ME/CFS specialist team, and doesn't recommend graded exercise therapy. The NHS says people with EDS can be taught ways to conserve energy and pace activities. Our ME/CFS guide has more.
From the NHS PoTS and fainting pages, PoTS UK and a Pilates teacher's case report; rolling onto your side to sit up is our suggestion.
See the movement on the 3D figure: Sit to stand from a chair
No trial has compared them in hypermobility. PoTS UK mentions the reformer only as a way to exercise lying down. On a reformer, lighter springs make the carriage less stable: in 18 women, a low-resistance spring made core muscles work harder than a fixed platform. A steadier set-up is likely easier to control when you're starting (our suggestion).
A 42-year-old woman with no connective tissue disease felt a "pop" in her neck during a reformer move and developed a spinal fluid leak, with a headache that eased when she lay flat. One case doesn't make the reformer dangerous, but it supports keeping weight off the neck.
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Getting too hot is a recognised PoTS trigger, so with PoTS choose an unheated class (our advice, from the NHS and PoTS UK). Without PoTS, extra heat to stretch further is the wrong goal for hypermobile joints anyway.
The Ehlers-Danlos Society says people with vascular EDS should exercise at low intensity only and avoid activities that cause blood pressure spikes and straining. In Pilates that means no heavy springs or resistance, no straining holds and no breath-holding (our reading). Discuss exercise with your specialist team first.
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With very fragile skin, as in classical EDS, the Society advises avoiding activities that cause friction. Pad straps and equipment, and skip moves that rub the skin (our suggestion).
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Forceful neck and spine manipulation isn't safe with EDS or HSD, the Society says. If a teacher or therapist offers to adjust your neck, say no.
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Hypermobility is common in children: a 2026 review estimated 17.2%, mostly from studies of children and teenagers. Trials are small. Exercise eased knee pain whatever the range in 26 children, targeted and general physiotherapy helped equally in 57, and 3 children did a Pilates programme. A Cochrane review of treatment is only at the planning stage. The HMSA notes that some children grow out of their problems. Our hypermobility exercise guide and children's exercise guide cover this.
Head on a pillow and knees bent; slide, lift and squeeze only as far as your pelvis stays still, and keep breathing.
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoSupine heel slideBeginner · No equipment
3D demoKnee foldBeginner · No equipment
3D demoDead bug heel tapsBeginner · No equipment
3D demoPelvic tilt into bridgeBeginner · No equipment
3D demoLying adductor ball squeezeBeginner · Other / check instructions
3D demoSupine isometric hip abduction (belt press)Beginner · A band
3D demoChest lift (Pilates curl-up)Beginner · No equipmentDo all of these on one side, then all on the other, opening and lifting only as far as your pelvis stays still.
Fists or forearms on the mat and elbows soft; hold planks for 15 to 20 seconds at first, as our hypermobility exercise guide suggests.
Sit for a minute before you stand, keep your knees soft, and keep a counter within reach for the balance work.
3D demoThoracic rotationBeginner · No equipment
3D demoSeated upper-back lift (sit tall, shoulders back)Beginner · A bench or box
3D demoSit to stand from a chairBeginner · A bench or box
3D demoWall push-upBeginner · A wall
3D demoSingle-leg standBeginner · A wall
3D demoSemi-tandem stanceBeginner · A wallStart with the supported Pilates class and do the strength routine on other days. On dizzy days, use the lying PoTS routine or the chair class.
A 20-minute Pilates class for hypermobile joints, HSD and hEDS: supported positions first, mid-range control, slow changes and steady breathing.
20 minBeginner17 movesOther / check instructions, A bandA 25-minute low-load routine for hypermobile joints: hip, trunk and shoulder control plus balance, done slowly in the middle of your range.
25 minBeginner15 movesA bench or box, A wallA 30-minute PoTS session that never asks you to exercise standing: easy intervals on a bike and rowing machine, lying leg strength, then legs up the wall.
30 minBeginner8 movesCardio machine, Other / check instructionsA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesA bench or box, Something with weightBalance practice in 10 minutes: tandem stance, single-leg stands, marches, heel walks, tree pose and floor transfers.
10 minBeginner7 movesA wall, A bench or boxA 20-minute mat Pilates workout for complete beginners. It covers breathing, spine position and the foundation moves, each with an easier option.
20 minBeginner13 movesNo equipmentChoose the control versions of each move and skip end-of-range stretches, as our hypermobility exercise guide says.
That you're hypermobile and any diagnosis such as HSD, hEDS or PoTS, which joints slip or hurt, and whether you get dizzy when you stand up (our suggestion).
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Supported positions, low loads and mid-range work, quality over quantity, and a teacher who asks how you felt afterwards. The PAA tells teachers: "If you are working with a hypermobile client that you are finding challenging to progress or that is experiencing pain after their session, refer them for an assessment and treatment with an EDS and HSD aware Therapist."
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The Ehlers-Danlos Society's summary says physiotherapy should be individual and focus on learning to control movement, with exercise graded to avoid flare-ups. People who'd had exercise advice from a physiotherapist were more likely to exercise a lot. Knowledge is patchy, though: in a Scottish survey, 80% of rheumatology physiotherapists and occupational therapists lacked access to outside training on HSD and hEDS, a 2026 editorial argues many physical therapists feel unprepared, and a physiotherapy article notes that many patients report pain and injuries from unsuitable treatment.
In the UK, check a physiotherapist on the Health and Care Professions Council (HCPC) register. Our clinical Pilates guide explains physio-led Pilates and how to find a class.
The NHS says to call 999 if someone:
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Lie down with your legs raised. If you can't, sit with your head lowered between your knees. Crossing your legs while standing, rocking up and down on your toes, clenching your fists, or, with PoTS, clenching your buttocks and tummy muscles can help.
After an injury, if:
After a knee injury, if it's very painful, swollen or bruised, you can't stand up or move your knee, or you think your kneecap came out and went back into place.
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The Ehlers-Danlos Society says partial dislocations (subluxations) "often resolve on their own or can be manipulated back into place at home", while "Dislocations often require attention from a doctor or PT". Follow the plan your physiotherapist gives you; the A&E list applies to a joint that stays out.
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NHS inform says to contact your GP practice urgently, or 111 if it's closed, if neck pain comes with a severe headache, with numbness, pins and needles, weakness or clumsiness in one or both arms that is getting worse, or with new problems with balance or walking. A headache that eased when lying flat was the main symptom in the reported spinal fluid leak.
Sore muscles after starting are "a normal response and can last for a few days". Talk to your physiotherapist about high levels of pain, pain in new areas, other symptoms getting worse, or changes in what you can do.
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It's the other way round. Overstretching beyond the normal range "may lead to instability", and the HMSA recommends Pilates and yoga focused on strength and control rather than flexibility. This rests on consistent expert advice rather than trials.
The trial measured how much hypermobility affected people's lives and their body awareness, not joint looseness, and the one study showing steady looseness was in pregnant women. What exercise changes is muscle strength, control and joint sense.
Not yet: one non-randomised online trial found modest effects with high drop-out, and the first randomised pilot is only now recruiting.
The NHS lists Pilates among lower-risk activities with EDS, about half of the flares reported in the trial passed or settled with changes, and none was known to be serious. The problem moves can be adapted or left out.
No trial has compared them in hypermobility. Jumpboard work is high impact, and one case report links a neck injury to a reformer class. Choose the teacher before the equipment.
Getting too hot is a PoTS trigger, and stretching further is the wrong goal for hypermobile joints.
It can be. The NHS lists Pilates among lower-risk activities with EDS, and the HMSA says it's worth trying when it's focused on strength and control rather than flexibility. In the one sizeable trial, a Pilates programme designed for hypermobility gave modest improvements, though the trial wasn't randomised and many people dropped out.
Not when it's adapted. In the online trial, 17% reported some extra pain or a flare; about half of those passed or settled by changing exercises, and none was known to be serious. The risks come from end-of-range stretching, locking joints and weight on the neck, which you can avoid.
The advice is the same as for hypermobility spectrum disorder, which the NHS says is treated in the same way as hEDS, and the online trial included people with either diagnosis. With vascular or classical EDS, check with your specialist team first.
Either can work if it's about strength and control rather than flexibility, as the HMSA puts it. Pilates has one sizeable trial in hypermobility, our yoga guide found no yoga trials, and no study has compared them. The Ehlers-Danlos Society advises against flexibility-focused sports if your joints are unstable.
Expert advice is to leave out moves that put weight on your neck, such as the roll-over and jack knife, and to keep stretches, twists and leg circles short of the end of your range. In planks and push-ups, use fists or forearms, keep your elbows soft and don't lock your knees. No trial has tested individual moves, and the two trials that tested range found no harm from going further.
It may be, with a teacher who knows hypermobility: springs can support or challenge you, and PoTS UK notes reformer work can be done lying down. No trial has compared reformer and mat Pilates in hypermobility, and jumpboard work is high impact, which the Ehlers-Danlos Society advises avoiding with unstable joints.
Often, because much of it is done lying down, which PoTS UK says is easier to tolerate. Do the lying moves first, sit for a minute before standing, drink two glasses of water beforehand, keep cool and cool down gradually. Avoid heated classes, because getting too hot can trigger PoTS symptoms.
It can strengthen the muscles around them and improve your control and sense of joint position, which is what protects hypermobile joints, but it won't tighten your ligaments. Body awareness improved in the online trial, and exercise with the feet on the ground improved joint sense in small studies.
The online trial asked for about 25 minutes at least 3 times a week, and people managed about 2.3 sessions a week. A Pilates teachers' body suggests starting with about 20 minutes and noticing how you feel over the next 48 hours.
Only what's genuinely tight, gently, while holding the bendy part still. Overstretching beyond the normal range may make joints less stable, so spend most of your time on strength and control.
That you're hypermobile and any diagnosis such as HSD, hEDS or PoTS, which joints slip or hurt, and whether you get dizzy when you stand up. A Pilates teachers' body advises its members to use supported positions, low loads and mid-range work, and to refer you on if sessions cause pain.
The evidence is tiny: 3 children did a Pilates programme, and two had less fatigue. In a children's trial, exercise eased knee pain whatever the range; our hypermobility exercise guide covers children.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
