Tongue-tie and Hypermobility

If tongue-tie runs in your family, you may also have heard about joint hypermobility, connective tissue conditions or Ehlers–Danlos syndromes (EDS). Some families and healthcare professionals have questions about whether these features could be connected, particularly when an infant has feeding difficulties, a restrictive lingual frenulum or concerns about healing after a tongue-tie division.

There are some interesting findings in the research, but the relationship is not straightforward. Studies have explored the presence or absence of oral frenula in people with EDS, and separate research suggests that tongue-tie can occur in families. However, these findings do not establish that hypermobility causes tongue-tie or that it affects healing after frenulotomy.

Understanding what is known, what remains uncertain and what the research has not yet answered can help families make sense of these discussions.

Understanding joint hypermobility and connective tissue

Joint hypermobility means that one or more joints can move beyond the range usually expected. Some people are naturally very flexible without experiencing problems. In others, hypermobility occurs alongside pain, instability or other symptoms and may be associated with a hypermobility spectrum disorder (HSD) or a connective tissue condition such as Ehlers–Danlos syndrome (Castori et al., 2017; Tofts et al., 2023).

Ehlers–Danlos syndromes are a group of heritable connective tissue disorders. Connective tissue helps support and connect structures throughout the body, including skin, ligaments, blood vessels and other tissues. Depending on the EDS subtype, features may include unusually flexible joints, stretchy or fragile skin, easy bruising and differences in wound healing. The characteristics and underlying mechanisms vary between subtypes, so EDS is not one uniform condition (Malfait et al., 2017).

Collagen is an important component of connective tissue, helping tissues maintain their structure and mechanical properties. However, connective tissue also contains other proteins and extracellular matrix components. It would therefore be too simplistic to assume that all hypermobility, tissue elasticity or wound-healing differences have one explanation or involve the same collagen type.

It is also important to distinguish joint hypermobility from a diagnosed connective tissue disorder. Being flexible, or having a family member who is flexible, does not automatically mean that someone has EDS or HSD (Castori et al., 2017; Tofts et al., 2023).

The lingual frenulum and Ehlers–Danlos syndromes

The lingual frenulum is the fold of tissue connecting the underside of the tongue with the floor of the mouth. It varies in appearance between individuals. Tongue-tie, also called ankyloglossia, describes a congenital variation in which the lingual frenulum restricts tongue movement. The presence of a visible frenulum alone does not establish whether a restriction is present or whether it affects feeding (Messner et al., 2020).

Research into EDS has explored an interesting finding: some studies have reported that the lingual frenulum, the lower labial frenulum or both may be absent or underdeveloped in people with particular EDS subtypes.

De Felice et al. (2001) reported an association between absent oral frenula and classical or hypermobility-type EDS in a small group of patients. However, later studies did not consistently reproduce the findings. Shankar et al. (2006), for example, concluded that the absence of the lower labial or lingual frenulum was not a useful clinical marker for EDS in their UK population. Machet et al. (2010) found that the absence of these structures could be a specific finding in their study population, but it was not present in everyone with EDS. A later study of children with EDS again reported an association, illustrating why this topic continues to be discussed (Savasta et al., 2019).

These studies concern the presence, absence or development of the frenulum. They do not establish that a frenulum which is present is necessarily more elastic, nor do they show that increased tissue elasticity causes a restrictive tongue-tie.

This distinction matters because three different observations should not be treated as equivalent:

• An absent frenulum: the structure cannot be identified, or appears to be absent, on examination.

• A present but unusually elastic frenulum: this is a possible feature that would need to be investigated directly; it cannot be assumed from the studies reporting absent frenula.

• A restrictive frenulum: the frenulum limits tongue movement. Its functional significance depends on the individual and cannot be determined by appearance alone.

The existing EDS research does not demonstrate that a baby with hypermobility has a frenulum that is present but so elastic that it causes, or disguises, tongue-tie. Nor does it establish that an absent frenulum means tongue movement must be unrestricted in every respect.

This is an important gap in the evidence. The relationship between connective tissue properties, the development of the lingual frenulum and tongue function needs further study before a specific explanation can be established.

For more on the relationship between anatomy and feeding, see Tongue-tie assessment tools: appearance, function and validation and A guide to understanding your baby’s oral function.

Pseudo-tie and hypermobility

The term pseudo-tie is sometimes used when a tongue appears restricted or its movement is limited, but the limitation may not be explained by a restrictive lingual frenulum alone. It is not a single, clearly defined diagnosis, and its use does not establish what is causing the observed movement pattern.

Tongue movement involves the interaction of oral structures, muscles, nerves and coordination. Feeding also depends on how these systems work together with the infant’s development, state and feeding task. Consequently, a baby may have feeding difficulties or limited-looking tongue movement for reasons other than a restrictive frenulum, and more than one factor may be present (Messner et al., 2020).

Could differences in connective tissue properties influence the way the frenulum moves or feels? This is a reasonable question for research, particularly given the published observations about absent or underdeveloped frenula in some people with EDS. However, there is not currently sufficient evidence to conclude that hypermobility causes pseudo-tie, that unusually elastic tissue explains restricted tongue movement, or that either feature can be identified reliably from an infant’s family history.

A term such as pseudo-tie should therefore not be taken as proof that a frenulum is normal, that it is restrictive, or that hypermobility is responsible. The relevant question remains what the assessment shows about the infant’s tongue movement and feeding, alongside any other factors that may be contributing.

Further reading is available in What does a tongue-tie assessment consider? and Infant oral anatomy: structure, function and feeding.

Family history and infant assessment

Family history is relevant to this topic for two separate reasons: tongue-tie itself may have a genetic component, and some forms of joint hypermobility and EDS have a hereditary basis. These are related areas of interest, but they are not evidence of one shared cause.

Tongue-tie is present from birth, and familial patterns have been reported. Klockars and Pitkäranta (2009) discussed inheritance in families with ankyloglossia, while Han et al. (2012) examined family histories in a group of 149 patients who had undergone frenuloplasty. Their findings suggested a hereditary component in some cases, although the authors’ proposed inheritance pattern cannot be assumed to apply to every family. Other reports have described different possible inheritance patterns (Moore et al., 1987; Klockars and Pitkäranta, 2009; Han et al., 2012).

The overall picture is that genetic factors may contribute to tongue-tie in some families, but its causes and inheritance are not fully understood. A family history does not mean that every child will have tongue-tie, and the absence of a known family history does not rule it out.

EDS is also a group of heritable conditions, although the genetic basis varies by subtype. For hypermobile EDS, a single causative gene has not been established for routine diagnostic testing in the way that genes have been identified for several other EDS subtypes (Malfait et al., 2017).

Assessing joint hypermobility in infants presents additional challenges because mobility and physical development change as children grow. The 2023 paediatric framework for joint hypermobility was designed for children from five years of age through biological maturity, rather than for diagnosing hypermobility in young infants (Tofts et al., 2023).

A family history of tongue-tie may therefore be relevant when considering an infant’s oral anatomy, just as a family history of hypermobility or a diagnosed connective tissue condition may be relevant to their wider health history. Neither history, on its own, establishes a diagnosis or explains an individual infant’s feeding difficulties.

My article on the causes of tongue-tie explores what is currently understood about its possible genetic and developmental influences.

Wound healing in the hypermobile population

After a frenulotomy, the small wound beneath the tongue goes through a normal healing process. Understanding this process helps distinguish expected changes in the wound from concerns about persistent restriction or recurrent symptoms.

Normal healing after frenulotomy

Following division of the lingual frenulum, a wound may be visible beneath the tongue. It can look red initially and then develop a white or yellow appearance as healing progresses. This change in colour is commonly part of normal oral wound healing and does not, by itself, mean that the wound is infected or that tongue-tie has returned. The wound usually becomes smaller and heals over approximately one to two weeks, although individual healing varies (Worcestershire Acute Hospitals NHS Trust, 2025).

The mouth has a moist environment and a rich blood supply, which support tissue repair. As with other wounds, healing involves overlapping stages of inflammation, tissue repair and remodelling. The appearance of the wound changes during these stages, and the visible healing process should not be confused with the final functional outcome.

When healing does not follow the expected course

Sometimes, healing can involve more substantial scar tissue or the return of restriction. After frenulotomy, the frenulum may appear to have re-formed or the tongue may again have restricted movement. These observations are often discussed under the term reformation, although the underlying explanation can vary. Residual tissue, healing and scar formation may contribute, and a return of feeding difficulties does not by itself prove that the frenulum has regrown (Messner et al., 2020).

It is important to distinguish normal wound healing from a problem with the outcome. A white or yellow wound, for example, is not sufficient evidence of abnormal healing. More relevant concerns include persistent or renewed restriction of tongue movement, ongoing feeding difficulties, or other symptoms that warrant reassessment. A wound that appears increasingly inflamed, is associated with fever, or accompanies a significant deterioration in feeding also needs appropriate clinical attention.

Connective tissue conditions and scar formation

Some people with EDS experience skin fragility, delayed wound healing or abnormal scar formation. These features vary between EDS subtypes and individuals, and the evidence on skin healing cannot automatically be applied to the oral mucosa or to a wound created by infant frenulotomy (Malfait et al., 2017; Angwin et al., 2024).

Scar formation itself is a complex process involving inflammation, collagen deposition and tissue remodelling. Research into hypertrophic scars and other abnormal scars helps explain these mechanisms, but it does not establish how an infant’s lingual frenulum will heal after division (Aarabi et al., 2007).

At present, there is not enough evidence to conclude that babies with joint hypermobility, a family history of EDS or a suspected connective tissue difference are more likely to develop restrictive scar tissue after frenulotomy. Nor is there sufficient evidence to predict an infant’s healing outcome from the apparent elasticity of their tissues.

Corticosteroid injections and emerging approaches to scar tissue

Corticosteroid injections are used in some settings to treat certain types of abnormal scar, including hypertrophic and keloid scars. Their use depends on the type, location and severity of the scar, and treatment can have adverse effects (British Association of Dermatologists, n.d.).

The use of corticosteroids injected into scar tissue following infant frenulotomy is a different question. This is an emerging concept, not an established routine treatment for tongue-tie reformation in babies. Evidence about steroid injections for skin scars cannot be assumed to demonstrate safety or effectiveness when injected into the tissues beneath an infant’s tongue.

A 2026 case report describing severe scarring after an unsuccessful infant frenulotomy specifically noted that intralesional corticosteroid treatment was not considered because of limited safety data and lack of regulatory approval for that use in infants with oral mucosal fibrosis (Salvage Frenuloplasty case report, 2026). A single case report cannot establish a standard of care, but it illustrates the uncertainty surrounding this approach.

Further research is needed before conclusions can be drawn about whether connective tissue conditions affect healing after frenulotomy, which infants might be at greater risk of abnormal scarring, or whether steroid injections have a role in managing oral scar tissue in this population.

Hypermobility and tongue-tie reformation

The possible relationship between hypermobility and tongue-tie reformation brings together several areas where the evidence remains incomplete: the development of the frenulum, connective tissue properties, normal wound healing and scar formation.

Research has described absent or underdeveloped oral frenula in some people with EDS. Other research has examined skin fragility and abnormal scarring in connective tissue conditions. However, these findings do not establish that a baby with hypermobility is more likely to experience reformation after frenulotomy.

It is also not yet known whether the properties of the lingual frenulum in infants with connective tissue conditions differ in a way that affects healing, or whether any such differences would have a clinically meaningful effect on tongue movement or feeding. These questions cannot be answered by extrapolating from skin wounds or from studies of absent frenula in people with EDS.

For families whose babies experience persistent or returning feeding difficulties after frenulotomy, the presence of a family history of hypermobility may be one part of the wider history. It is not, however, proof that connective tissue differences caused the outcome. The same applies to a family history of tongue-tie: familial patterns may exist, but they do not determine how an individual baby will heal.

What the evidence means for families

There are three separate questions that are sometimes grouped together in discussions about tongue-tie and hypermobility:

• Can tongue-tie run in families? Research suggests that tongue-tie may have a genetic component, although the precise causes and inheritance patterns remain uncertain.

• Can EDS be associated with differences in oral frenula? Some studies have reported absent or underdeveloped frenula in people with EDS, but findings are inconsistent. This is not the same as demonstrating that a present frenulum is unusually elastic or restrictive.

• Does hypermobility affect healing after frenulotomy? There is currently insufficient direct evidence to establish that it increases the risk of abnormal scar formation or reformation in infants.

These questions are worth investigating because they may help improve understanding of oral anatomy, feeding and healing. However, they should not be treated as if research has already established a single explanation linking all three.

Conclusion

Tongue-tie may have a genetic component, and joint hypermobility and EDS are relevant to connective tissue research. Studies have also explored the absence or underdevelopment of oral frenula in people with EDS. What remains uncertain is whether connective tissue differences influence the elasticity or function of a frenulum that is present, or whether hypermobility has any effect on healing after infant frenulotomy.

Normal wound healing, persistent restriction and reformation are not interchangeable, and the evidence about skin scarring cannot simply be transferred to the lingual frenulum. Corticosteroid injections into oral scar tissue are an emerging concept, with important unanswered questions about their use in infants.

This remains an area for further research. As evidence develops, it may help clarify whether any meaningful relationship exists between hypermobility, tongue-tie and healing, and whether that knowledge should inform future clinical guidance.

References

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Angwin, C. et al. (2024) ‘Skin fragility and wound management in Ehlers–Danlos syndromes: a report by the International Consortium on Ehlers–Danlos Syndromes and Hypermobility Spectrum Disorders Skin Working Group’, Clinical and Experimental Dermatology, 49(12), pp. 1496–1503. Available at: https://doi.org/10.1093/ced/llae201

British Association of Dermatologists (n.d.) Keloid scars. Available at: https://www.bad.org.uk/pils/keloid-scars/

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Klockars, T. and Pitkäranta, A. (2009) ‘Inheritance of ankyloglossia (tongue-tie)’, Clinical Genetics, 75(1), pp. 98–99.

Machet, L. et al. (2010) ‘Absence of inferior labial and lingual frenula in Ehlers-Danlos syndrome: a minor diagnostic criterion in French patients’, American Journal of Clinical Dermatology, 11(4), pp. 269–273. Available at: https://doi.org/10.2165/11530090-000000000-00000

Malfait, F. et al. (2017) ‘The 2017 international classification of the Ehlers-Danlos syndromes’, American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), pp. 8–26. Available at: https://doi.org/10.1002/ajmg.c.31552

Messner, A.H. et al. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. Available at: https://doi.org/10.1177/0194599820915457

Moore, G.E. et al. (1987) ‘Familial ankyloglossia (tongue-tie)’, Journal of Medical Genetics, 24(12), pp. 715–716.

Savasta, S. et al. (2019) [Study on oral manifestations in children with Ehlers–Danlos syndrome]. [Bibliographic details to be confirmed before publication].

Shankar, S., Shirley, E. and Burrows, N.P. (2006) ‘Absence of inferior labial or lingual frenula is not a useful clinical marker for Ehlers-Danlos syndrome in the UK’, Journal of the European Academy of Dermatology and Venereology, 20(10), pp. 1383–1384. Available at: https://doi.org/10.1111/j.1468-3083.2006.01736.x

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Worcestershire Acute Hospitals NHS Trust (2025) Tongue-tie division: information for parents and carers. [Local NHS patient information; confirm the exact title and current URL before publication].