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Posted By Alan Hakim, June 10, 2013
  • Fatigue is a common and often disabling finding in many musculoskeletal conditions. It is a very common concern in hypermobility disorders. Those with this type of fatigue will know that it is much more than the tiredness experienced after exercise or a busy day at work; it is often an overwhelming lack of energy that may appear after even the most minimal activity.
  • The cause for such profound symptoms is unclear and may be related to pain, autonomic dysfunction, and poor sleep patterns and sleep quality. Addressing these issues may help relieve the severity of the fatigue.
  • It is important that other medical causes of fatigue have been excluded. This involves a clinical assessment and blood tests to rule out anaemia, endocrine disorders (such as underactive thyroid, or under active adrenal glands), prolonged or recurrent infections, inflammation that may require further investigation, low vitamin levels (such as B12, folate and Vitamin D), and organ disorders such as kidney or liver problems.

This figure is a pictorial representation of the things that should be considered as causing severe fatigue. The management of each of these should help reduce the level of fatigue.


  • Treatment is based on addressing the underlying issues. These might include antidepressants, anti-anxiety drugs, sleep aids and analgesics, and very importantly lifestyle changes including pacing, changing sleep pattern, exercise, and even a change of job or hours of work.
  • There is very little published evidence in support of treatments specifically for fatigue. Some individuals find nutritional supplements replacing deficiencies of B vitamins and trace minerals (e.g. Zinc, Selenium, Manganese) to be helpful. Carnitine, Co-enzymeQ10, and 5-HTP, are often tried as they are considered to be effective in boosting the immune system, raising energy levels, and improving cognitive functioning. However there is little scientific evidence for these therapies. As long as there is no concern over interaction with medications or other aspects of a person’s health (please consult a doctor if not sure) then a pragmatic approach is to try them for 2-3 months and see if they help but be sure to read the label and understand that one takes these at one’s own risk when they are not medically prescribed.

Dr Alan J Hakim MA FRCP
Consultant Physician and Rheumatologist, Chief Medical Advisor and Trustee, HMSA

V.2. Updated March 2017. Review date March 2018.


Castori M, Morlino S, Celletti C, et al. Management of pain and fatigue in the joint hypermobility syndrome (a.k.a. Ehlers-Danlos syndrome, hypermobility type): principles and proposal for a multidisciplinary approach. Am J Med Genet A. 2012 Aug;158A(8):2055-70.

Hakim A, De Wandele I, O’Callaghan C, Pocinki A, Rowe P. 2017. Chronic fatigue in Ehlers–Danlos syndrome—Hypermobile type. Am J Med Genet Part C Semin Med Genet 175C:175–180.

Hakim AJ, Grahame R. Non-musculoskeletal symptoms in Joint Hypermobility Syndrome: Indirect evidence for autonomic dysfunction. Rheumatology. 2004; 43: 1194-5.

Nijhof SL, Rutten JM, Uiterwaal CS, et al. The role of hypocortisolism in chronic fatigue syndrome. Psychoneuroendocrinology. 2014 Apr;42:199-206.

Voermans NC, Knoop H, van de Kamp N et al. 2010. Fatigue is a frequent and clinically relevant problem in Ehlers-Danlos Syndrome. Semin Arthritis Rheum. 2010 Dec;40(3):267-74.




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