Hypermobility and Throat Problems

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Adam Foster

Director at The Fibro Guy

Adam Foster is the founder of The Fibro Guy and one of the leading voices in hypermobility, EDS, and chronic pain rehabilitation. A former Reconnaissance Soldier, he developed chronic pain after an IED blast in Afghanistan and built his approach from the ground up when the medical system had no answers. Since 2009 he has worked with thousands of people across eight countries, drawing on pain neuroscience, motor learning, and sensorimotor rehabilitation. He co-authored "No Pain, No Pain" with trauma psychologist Dr Mairi Harper, directed the documentary "Invisible Monster," and has been featured in Forbes, BBC Radio 4, ITV News, LiveScience, and The Telegraph.

Latest posts by Adam Foster (see all)

• Fibromyalgia and Central Sensitisation, What Is It in Plain English? - 8 October 2026
• Which supplements are worth taking when you’re hypermobile - 4 October 2026
• Hypermobile Wrists: Why They Hurt, Which Brace to Use, and How to Build Control - 4 October 2026

You choke on water. Not on steak, not on dry bread, on water. You choke on your own spit while sitting perfectly still and saying nothing. You’ve likely done it on a work call, at a funeral, or in a supermarket queue.

And the advice, if anybody gave you any, was to slow down. Take smaller sips. Stop talking while you drink. Be more careful.

So, you drew the obvious conclusion, which is that you’re careless, or clumsy, or as more than one person has put it to us, just not very good at being a person. That conclusion is wrong though, and what replaces it isn’t all too complicated. It only needs you to know what has to happen inside a swallow, and how little room there is in it. The clinical word for the whole business is dysphagia.

What has to happen in a swallow

Your throat is a crossroads with a terrible design, as air goes down the front pipe into your lungs. And food and drink go down the back pipe into your stomach. Both routes start in the same place, and on every swallow, the thing you’re swallowing travels straight across the top of the airway.

The way your body handles that isn’t a lid coming down over a hole, although the epiglottis, the flap of cartilage that sits at the back of your tongue, does flop backwards and help. The main event is that the entrance to the voice box, the larynx if you’ve ever seen it written down, shuts itself. The narrow corridor between the vocal folds and the base of the tongue closes up. The vocal folds squeeze together. The whole voice box lifts and tucks forward under the tongue, which pulls it out of the firing line and at the same time, hauls open the ring of muscle at the top of the gullet so the drink has somewhere to go.

That closure is the single thing airway protection actually relies on ^[1]. Not the epiglottis, not the hyoid, the little floating bone in the front of your neck that all the swallowing muscles hang off, which as it turns out, is a fairly weak predictor of whether anything goes down the wrong way ^[2].

And it’s a timing problem far more than a strength problem. Across people with swallowing difficulty, the closure being late or incomplete predicts things getting into the airway better than the hyoid measurements do ^[2]. How late you ask? Delaying that closure by a tenth of a second raises the odds of airway invasion, which is the technical way of saying the drink got in where the air goes,^[3]. A tenth of a second. That’s the entire margin you’re working with, on every swallow you make, including all the ones you never notice making.

So, the question was never really whether your throat is weak (which gets hammered around the internet). It’s whether or not the door shuts at the right moment.

Why water

Thick things go down fine. Yoghurt, soup, custard, a mouthful of mashed potato, no trouble at all. But water seems to be the biggest issue, and that inversion is the reason people end up quietly wondering whether they’re slowly going insane.

You’re not by the way, and it’s one of the better established findings in this whole field. Thin liquid carries the highest risk of going where it shouldn’t, and the risk drops as the drink gets thicker ^[4]. In people with swallowing problems after brain injury, liquid going down into the airway, which is what the word aspiration means, fell from roughly a fifth of swallows on thin liquid, to about one in ten at nectar thickness, which is about the consistency of a smoothie, to about one in twenty at pudding thickness, which is about a set yoghurt ^[5]. A model of a human throat, built to the right anatomy and filmed, put water at around ten times the aspiration risk of a mildly thickened drink ^[6].

The reason though, comes down to speed and cohesion. Water arrives at the top of the gullet earlier than thick liquid, because nothing is holding it back. It also won’t hold together. A cohesive mouthful travels as one object, whereas water splits, runs round edges and finds the gap. Also, how safely a liquid behaves isn’t explained by thickness alone, because how well it sticks to itself matters too ^[7].

So, water isn’t dangerous, It just leaves your throat the smallest possible window between the drink arriving and the door being shut, and if the timing is even slightly out, water is the substance where you’re going to notice first.

There is also a part of this that gets weirder. In people with a healthy swallow, the vocal folds close earlier and stay closed for longer with thinner liquid over thick ^[8]. The system sees the fast thing coming and shuts early, which is a pretty clever adaptation, and it’s also the adaptation that goes first: in people whose swallow is more impaired after a stroke, the earlier closure that thin liquid should have triggered is no longer there ^[9].

And it’s the answer to the question you most likely arrived here with. You don’t choke on water because water is inherently bad for your hypermobile body. You choke on water because water really puts to the test that automatic, unconscious, fraction of a second adjustment that nobody ever has to think about. When that adjustment is slightly less fine tuned than it should be, everything thick still works, but the thinner liquids are where you’re going to notice the issue. It’s exactly the wrong way round from what a reasonable person would ver expect, which is precisely why you keep being told you can’t possibly be choking on water.

Saliva, and choking on nothing at all

Saliva is the same problem with the safety catch removed.

You make it constantly and you swallow it constantly, and almost none of those swallows are in your attention. The saliva swallow happens while you talk, while you laugh, while you lie flat, while you read, and above all while your attention is entirely somewhere else. It’s also very thin.

So, every protective adjustment described above, all the ones that depend on the system knowing something is coming and getting the timing right, is being asked to run in the background with no warning and no preparation, on a thin substance.

That’s also why it happens with an empty mouth, which is the detail people find genuinely uncanny and often won’t mention in case they sound mad. You weren’t eating. You weren’t drinking. You were sitting on the sofa. There was still something in your throat, because there’s always something in your throat, and one of the swallows you never noticed making went the wrong way.

Night time is the same mechanism with even less supervision, and it’s the version that frightens people the most. Waking up gasping, mid cough, convinced for a second that you aren’t going to get a breath. Everything you do consciously in the daytime to stay safe, the small sips, the chin tucked down, the concentrating, is unavailable to you asleep. Being woken like that is a reason to get the swallow looked at properly rather than a reason to lie there and hope for the best. But the truth is, this is something we find that people just kind of ignore.

Is the hypermobility doing it?

Mostly yes, in the sense that matters the most to you. Throat symptoms turn up in this population often enough that treating them as unrelated is the odd position, not the other way round. I’ve had this conversation in the studios more times than I can count, and it tends to open with somebody apologising for bringing it up at all.

Among 289 people with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder, hEDS and HSD from here on, seen at a clinic that does nothing but throats (they do exist, little unicorns), 33.9% reported difficulty swallowing and 27.0% reported symptoms of the voice box not working properly, with no clear difference between hEDS and HSD ^[10]. In a large international survey of people with EDS or HSD, the swallowing burden came out high on EAT-10, a swallowing questionnaire, with a mean score of 11.9, and hEDS scored worse than HSD on every item of it ^[11]. Among people with joint hypermobility syndrome who’d been sent for gullet testing, swallowing difficulty was present in 70% against 40% of the comparison group ^[12]. And set against controls, symptoms coming from the gullet affected 56% of people with hEDS or HSD against 6% ^[13].

Two limits on that though (you know I love a good hedge), and both matter. Most of those people were sitting in a specialist clinic or filling in a survey because they already had a problem, which tells you the burden is real, but doesn’t tell you the rate across everybody with hypermobility. And every one of those figures is somebody reporting a symptom, not a camera watching them swallow.

But you didn’t come here for a prevalence figure. You came because you already know it happens, and what you want to know is what it is, and whether or not the person that told you the throat has nothing to do with hypermobility was right.

What people say is causing it

Five explanations are in circulation, and one of them has pictures behind it.

It’s lax tissue, behaving like any other loose joint.
This is the one with the pictures. The review that pulled together the laryngeal findings in EDS reports the same things recurring: the arytenoids, the small paired cartilages that swing the vocal folds open and shut, prolapsing or subluxing, the cricoarytenoid joint, where those cartilages sit on the ring of cartilage beneath them, subluxing or seizing, and instability of the whole voice box and hyoid assembly, often with the vocal folds still moving perfectly well ^[14]. A scan taken while somebody with hEDS was actually speaking caught an arytenoid subluxing, which means that what looks on a static examination like a paralysed vocal fold, can in fact be a joint that won’t stay put (probably not news to you though) ^[15]. There’s a report of a whole larynx dislocating sideways and then doing it again ^[16], and a report of the airway being obstructed by hypermobility of the suspensory tissue slung above the hyoid ^[17].

So, that one isn’t invented. The caveat her though, which the review itself states, is that these findings are mixed and uncommon in the published literature, and that not everybody found to have that instability has trouble with their voice or their swallowing ^[14]. It’s a real thing that happens to some people, and it isn’t the explanation for everybody who chokes on water. Whether it’s what’s going on in your throat isn’t something you can settle off a page, and it is exactly the sort of thing a camera should be pointed at.

It’s the hyoid bone.
This one gets repeated with a fair bit of confidence. The hyoid does matter, don’t get me wrong, and outside hypermobility, reduced hyoid movement does track with things getting into the airway ^[2]. But the reviews that went through the EDS laryngeal literature, report finding no study that measured how far the hyoid actually travels during a swallow in adults with hEDS or HSD ^[18][14]. Hyoid and voice box problems do get described in EDS clinics, and hyoid subluxation has been written up ^[18]. On top of which, in the wider swallowing literature the hyoid measurements are the weaker predictor and the closure timing is the stronger one ^[2]. So even if the hyoid does behave differently in hypermobility, it’s probably not the variable deciding whether your tea goes down the wrong way.

It’s a floppy palate.
The soft palate does have a job in swallowing, which is sealing off the back of the nose so that nothing comes out of it, and when that fails, you get drink coming out of your nose, which is a specific and recognisable thing and isn’t the same complaint as choking. The instability that has actually been seen and photographed in this population sits lower down, at the voice box and the tissue slung around it ^[14][17], and that’s where the attention belongs.

It’s all just dysautonomia,
meaning the autonomic nervous system, the part of you that runs heart rate, blood pressure and gut without consulting you about any of it. This one is popular and the measurements don’t back it. When symptomatic people with hEDS or HSD were put through pressure testing of the gullet, the most common result was a normal study at 61.9%, weak but not absent muscle activity accounted for 29.1%, and being hypermobile didn’t come with more abnormal motility than the comparison group had, once the other differences between the groups were accounted for ^[19]. An earlier group found minor motility abnormalities, meaning a gullet that moves but doesn’t move well, in 40% of those with swallowing difficulty, and a functional pattern, meaning symptoms without a matching abnormality, in 60% ^[20]. The imaging is thinner still: at one specialist centre, six people went for a filmed barium swallow and three of them showed mild to moderate difficulty, with nothing recorded about what got into the airway, what reached the entrance without going in, or what was left behind afterwards ^[21].

Which isn’t to say the autonomic side is irrelevant, because it clearly modifies things. People with joint hypermobility who also had postural tachycardia syndrome scored worse for both swallowing and reflux than those without it ^[20], and in one hypermobility group POTS came out as an independent predictor of gut motility problems ^[21]. So it’s worth ruling in or out, but it’s not the full picture. A review looking at a different condition went hunting for studies that measured swallowing difficulty and autonomic function in the same people, and reported finding none ^[22], which tells you roughly what settling this properly would take.

Water is too thin. Not wrong, just the worst way of putting it, and the better version is above.

When the tests come back normal

You get the referral. You get looked at. And somebody tells you there’s nothing structurally wrong, which lands as: so there’s nothing to explain, which lands as: so it’s you.

That outcome is in the studies too, and it not a comment on you. In one specialist centre series of people with EDS who had swallowing complaints, the swallow through the mouth and throat came back normal in all of them, which led the authors to argue that when people with EDS report swallowing symptoms, the gullet further down is where to look ^[23]. In the pressure testing above, a normal study was the single commonest finding ^[19]. And the review of throat and voice problems across EDS is blunt about it as well: swallowing abnormalities and choking keep turning up as clinical problems, and their causes and their treatments are still not well defined ^[24].

A normal test isn’t a verdict on whether the thing happens. It’s a statement about what one camera, pointed at one part of your throat, while you swallowed, was able to see.

There’s a second route that explains rather a lot of what gets left over also, and it’s sensory rather than structural. Your voice box isn’t simply a valve. It’s one of the most densely monitored pieces of tissue you own, because it’s the last checkpoint before your lungs. When that monitoring turns its sensitivity up, the pattern that appears is recognisable: odd sensations in the throat, a cough reflex that goes off far too readily, the vocal folds slamming shut when they shouldn’t, a chronic cough, the feeling of a lump, and a voice that goes tight and tired because the whole apparatus is working too hard ^[25][26]. In EDS specifically, cough, breathlessness and episodes of the voice box closing against the airway are reported as recurring problems ^[27][28]. One series described laryngospasm, which is the voice box clamping itself shut, treated by blocking the nerve that supplies sensation to it, with the authors suggesting an oversensitive vagus nerve as the reason ^[23]. That link is drawn from the wider cough and voice literature rather than from sensory testing done in EDS, so hold it as the best available explanation rather than a settled one.

It also explains the tickle. The tickle isn’t nothing, and it isn’t anxiety (that one gets thrown about a bit). It’s a system that has decided the airway needs to be watching a little closer, which, given what has been happening to you at dinner for years, is not an unreasonable conclusion for it to have reached.

When it gets stuck instead

Food lodging is a different problem, in a different place, and the answers to it are different still. Choking is a timing failure at the crossroads. Getting stuck happens further down, in the gullet, after the dangerous bit is over: it tends to feel like it’s at the bottom of your breastbone rather than up in your throat, it involves dry or starchy food far more than water, and it hurts rather than makes you cough. If that’s what happens to you, it’s a gullet thing rather than an airway thing, which is exactly what the specialist centre work above points at ^[23].

The reason the two get muddled up so much is that the same people often have both, and the same appointment often addresses neither.

Reflux

Throat symptoms in hypermobility get put down to reflux almost reflexively, and the picture is less tidy than that. The larger pressure testing work found that most symptomatic people with hEDS or HSD had a normal study, and that being hypermobile didn’t come with more abnormal gullet motility than the comparison group had, once the other differences were accounted for ^[19]. Reflux scores did come out higher in the hypermobile group who also had POTS ^[20]. And where symptoms and measured physiology don’t line up, the explanations on the table include an oversensitive gut, hypervigilance, autonomic involvement and irritation from reflux, rather than one clean structural fault ^[19][12]. So reflux is worth treating if you’ve got it, and it’s a poor reason to stop looking at the swallow.

How worried should you be

The fear is rarely about the next coughing fit. It’s a slow background suspicion about how this eventually ends, and nobody addresses it in a quick in and out appointment. So: the thing that turns fluid going down the wrong way into pneumonia isn’t the single event. How much an aspiration matters depends on the person it happens to, on what went down, on what gets left behind afterwards, on oral health, on sensation and on how mobile somebody is ^[29].

That isn’t reassurance for its own sake, and the evidence points the same way. Thickening people’s drinks reliably reduces what you can see going into the airway on imaging, and the reviews that went looking for a matching reduction in pneumonia, death, dehydration or weight loss didn’t find convincing evidence of one ^[30]. Meanwhile, the studies that let carefully selected people with known swallowing problems drink plain water found no increase in lung complications, and often better hydration or satisfaction ^[31]. Put those two together and the picture is consistent. Thin liquid ending up where it shouldn’t be isn’t, on its own, the thing that hurts people.

So, if you’ve nothing else stacked on top, choking on water and coughing it straight back out is the protective system working rather than failing. The cough is the protection. A cough that clears it is the good outcome.

What should change your mind and get you seen:

• It’s happening at nearly every meal, or it’s clearly getting worse over months rather than sitting at the same level for years.
  
• You’re losing weight, or you’ve started avoiding foods and drinks, or meals have quietly become something you dread and put off.
  
• You keep getting chest infections, or a cough that hangs around for weeks after a bad episode.
• You’re waking at night gasping or coughing on saliva.
  
• Things go down the wrong way without you coughing at all, which sounds the least dramatic and matters the most, because the cough is what’s protecting you.
  
• Anything is genuinely getting stuck, or swallowing has become painful.
  
• Your voice changes for days after an episode, or you get breathless or noisy breathing in.

None of that is a hypermobility list. It’s the ordinary list, and that’s the point. Having a connective tissue diagnosis doesn’t exempt you from everything else that causes swallowing trouble, and a new or changing swallow deserves the same look it would get in anybody.

What actually helps, and what to ask for by name

Ask for a swallowing assessment, and ask for it by its instruments.
The two tests that actually watch a swallow are a filmed barium swallow, which is x ray video of you drinking, and a fibreoptic endoscopic evaluation of swallowing, known everywhere as FEES, which is a camera passed down through the nose to look at the throat directly. Those two are the recommended methods for assessing swallowing through the mouth and throat, and particularly where silent aspiration is the worry, meaning things going down the wrong way without the cough ^[32]. Overall they perform similarly, but they aren’t interchangeable: FEES tends to be the more sensitive of the two for picking up aspiration, penetration and leftover residue, while the barium video shows the mouth phase and the mechanics of the whole swallow better ^[33][34]. If your worry is that things are going down without you knowing, FEES is the one to name.

One thing worth asking when you get there is whether they’re scoring it against a standard scale, rather than describing what they saw. Reading a swallow video by eye alone turns out to be only moderately reliable ^[35], which isn’t a reason to distrust the test and is a good reason to ask for the version with numbers attached.

The person who runs those and does the rehabilitation afterwards is a speech and language therapist. That’s the referral to ask for by name, and it’s the one that gets missed, because throat symptoms get routed to ENT, to gastroenterology, or to nobody at all, depending on which word you happened to use in the appointment.

Thickening, and what it actually gets you.
This is the intervention with the most evidence behind it, and it comes with a bill. After a stroke, the proportion of people swallowing safely went from 41.2% on thin liquid to somewhere between 71.9% and 95.6% once the drink was thickened ^[36]. In older people with severe swallowing problems, only 16.25% managed thin liquid safely, and aspiration fell as low as 1.19% at the thickest level tested, with very little further gain past the middle of that range ^[37]. The level matters too: barely thickening a drink adds very little, and the real reduction starts at what gets called mildly thick ^[4].

Three things to hold alongside that. Those trials were run after stroke, in neurodegenerative disease and in older adults with severe swallowing problems, so the numbers describe those groups. Thickened drinks carry a genuine cost, including dehydration, people simply not liking them, residue left behind, and effects on how medication and water are taken up ^[38][39]. And as above, what thickening reliably buys is a better picture on the scan, which isn’t the same thing as a better outcome for your lungs ^[30].

Which points at the sensible version of this rather than the clinical one. You don’t need a tub of thickener to notice that a smoothie is easier than water. If thin drinks are the problem and thick ones aren’t, that’s information, and it’s worth taking to an assessment rather than keeping to yourself.

Get the POTS question answered if it’s still open.
Not because POTS is the swallow problem, because on the evidence above it isn’t, but because swallowing and reflux scores both ran worse in the hypermobile group who had it ^[20].

Tablets and capsules.
Small, specific, and it comes up constantly. A tablet is a dry solid you’re asked to launch backwards with a mouthful of the one liquid that’s hardest for you to manage, usually in a hurry, usually standing at the sink. Nothing in that is a personal failing. Worth asking your pharmacist whether the same medication comes as a liquid, a dispersible tablet, a patch or a smaller size, and whether yours can be taken with food rather than water, because plenty can and nobody mentions it. If you’re already using a thickened drink, say so, because thickened liquids carry their own burdens, including effects on medication ^[39]. And don’t dry swallow tablets to dodge the water, because that swaps one problem for a worse one further down.

The things genuinely within your control at the table.
You’ve already been told to slow down and be careful and it was useless, so here’s the version with a reason attached. Sit up properly, and stay up for a while afterwards, because gravity is free and it’s on your side. Don’t drink while you’re laughing or mid sentence, which isn’t the same instruction as don’t talk, and is the only part of be more careful that was ever worth anything. Notice which textures are reliable for you and which aren’t, and write it down rather than trusting yourself to remember, because that pattern is the most useful thing you can hand a clinician. And if a coughing fit starts, let it finish. Suppressing it to be polite is the one manoeuvre with nothing at all to recommend it.

Where to start

If you’ve never raised this with anybody, the sentence that works isn’t “I think I might have dysphagia”. It’s: “I choke on thin liquids and on my own saliva, including when I’m not eating, and I’d like a swallowing assessment.” That’s specific, it names the symptom pattern instead of a diagnosis, and it’s very hard to route to nowhere.

If you have raised it and been told the throat isn’t connected to the hypermobility, you now have a reason to go back. Throat symptoms turn up in this group at rates nobody should be waving away ^[10][11]. Laryngeal instability in this population has been seen and photographed ^[14][15]. And the reviews of this field say themselves that what exists so far is small, mixed and largely uncontrolled, and that standardised testing is the thing needed next ^[14][24].

And if you’ve spent years quietly concluding that you were careless: you weren’t. You were running a timing problem measured in fractions of a second, on the least forgiving substance there is, with no warning and no way of practising it. It’s a remarkably unhelpful thing for a body to do. It isn’t a character flaw, it’s called dysphagia, and there’s somebody out there whose entire job is this.

Adam

References

[1] Vose, A. and Humbert, I. (2018) ‘“Hidden in Plain Sight”: A Descriptive Review of Laryngeal Vestibule Closure’, Dysphagia. https://doi.org/10.1007/s00455-018-9928-1

[2] Smaoui, S., Peladeau-Pigeon, M. and Steele, C.M. (2022) ‘Determining the Relationship Between Hyoid Bone Kinematics and Airway Protection in Swallowing’, Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/2021_jslhr-21-00238

[3] Shu, K., Perera, S., Mahoney, A.S., Mao, S., Coyle, J.L. and Sejdić, E. (2022) ‘Temporal Sequence of Laryngeal Vestibule Closure and Reopening is Associated With Airway Protection’, The Laryngoscope. https://doi.org/10.1002/lary.30222