Understanding joint hypermobility and the Beighton score

Estimated reading time: 6 minutesSadly, I still encounter clients in my clinic who consultants and physicians have dismissed because they do not score high on the Beighton score. If this continues to happen and diagnosis is delayed, patient outcomes will not improve as fast as they could. 

The Beighton score is a guide; it should not be used as a definitive decision-making tool for diagnosing Ehlers-Danlos Syndrome or symptomatic hypermobility. We will discuss the  Beighton score in greater detail below, but it is important to recognize that this screening tool only includes certain joints in the body.

I see patients who are clearly hypermobile in other joints, but aside from the presentation of hypermobility in some joints, they also have other symptoms that have been overlooked. Once a doctor has made a decision based on the Beighton score, it appears to be difficult to have other symptoms taken into account and considered as part of a wider syndrome such as EDS.

Part of the issue patients face is that a diagnosis of EDS or HSD depends on a clinical assessment and the practitioner’s knowledge of the condition. If the practitioner is not fully versed in the 2017 diagnostic criteria and the multi-systemic nature of these conditions, then the correct diagnosis could be missed.

To use only the Beighton score is an outdated and simplistic approach that EDS and HSD are not going to fit into. This must change.

Differences between joint hypermobility and hypermobility syndromes

As we’ve said before, hypermobility, or the ability of a joint to move beyond its normal range of motion, isn’t necessarily a problem. It may be beneficial in certain sports or performing arts.

However, when there is generalized joint hypermobility (GJH) throughout the body, it points to a connective tissue disorder like Hypermobility Spectrum Disorder or Ehlers-Danlos Syndrome. One way that GJH is currently assessed is through the Beighton Score (1). It is part of the current diagnostic criteria for hEDS.

Generalized Joint Hypermobility or GJH is a descriptor and is defined as joint hypermobility in four limbs and axial skeleton – the skull, vertebral column, and rib cage (2).

Hypermobility exists on a spectrum from localized joint hypermobility in a single joint to a body-wide connective tissue disorder due to alterations in collagen production like Ehlers-Danlos Syndrome, resulting in systemic ligament laxity (2).

There is some controversy in the literature about how valid the Beighton Score is. Let’s learn a little more and see what researchers and specialists have to say about it.

What is the Beighton score?

The Beighton score was developed in the late 60s, and the current form was first published in 1973 by Beighton et al. in the context of assessing the mobility of joints in an African population. The authors recognized at this time that “hypermobility may well be of considerable clinical significance (3).”

They wanted to see how hypermobility might be related to things like age and sex, as well as what they termed “non-specific musculoskeletal complaints.” It was originally intended to be used as a screening tool, not a clinical diagnostic (2).

The scale consists of a dichotomous (can be yes or no in this case) assessment of hypermobility in 9 areas.

The nine-point scoring system explained

The assessment includes 9 points for a score of 0-9, with higher scores meaning greater joint laxity.

The 9 points include (3, 4):

1. Passive dorsiflexion of the little fingers beyond 90 degrees – 1 point for each pinky.
2. Passive apposition of the thumbs to the flexor aspect of the forearm -1 point for each thumb.
   1. The thumb can be pushed down to touch the forearm.
3. Hyperextension of the elbows beyond 10 degrees – 1 point for each elbow.
4. Hyperextension of the knees beyond 10 degrees – 1 point for each knee.
5. Forward flexion of the trunk with knees fully extended so that the palms of the hands rest flat on the floor – 1 point
   1. This means bending forward at the waist with straight legs and laying the hands flat on the floor.

Aleksandra Lacheta, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

How to interpret Beighton score results – When is a Beighton score considered high?

Different studies have used different cut-off points with a score of greater than or equal to 4 points to GJH in adults – while others have used cut-offs of 3, 5, or 6 (4).

It is also not straightforward in children because children are generally hypermobile, which decreases as they grow. Because of this, a higher threshold is often indicated (4).

The 2017 diagnostic criteria published by the International Consortium on The Ehlers-Danlos Syndromes use different cutoff ranges for different stages of life (5):

• ≥ 6 for children before puberty and adolescents
• ≥ 5 for Women and Men who have gone through puberty up to the age of 50
• ≥ 4 For those older than 50

The Beighton Score is only a component of the diagnostic criteria. As discussed above, we cannot rely solely on the Beighton score to make a diagnosis. It is a useful guideline, an indicator at best, but I would recommend other joints are also assessed, plus a full medical history of all other issues.

The Beighton score will not address the wide range of patient’s symptoms, including pain, fatigue, gastrointestinal issues, or dysautonomia. Use the Beighton Score as a screening tool, not a standalone diagnostic test. To have a full patient evaluation, combine the BS with a thorough clinical history – start to connect the dots. If you can’t connect the issues, think connective tissues.

Strengths and limitations of the Beighton score

According to a systematic review paper written by Dr. Malini Alexander, there are several reasons the Beighton Score is criticized, including:

• It only measures four joints – many people have hypermobility in other joints that are not assessed
  • It has a bias for upper limbs, doesn’t assess the lower limb, and can lead to false negatives – hello, bendy ankles!
  • For example, the shoulder is not assessed – this is one of the most problematic joints. One study found that there is a poor correlation between the Beighton score and shoulder hypermobility (6).
• It was developed as an epidemiological tool to assess a large population – not as a diagnostic tool. There is no description of why those specific joints were chosen.
• There is no agreement for cut-off scores, and there is no agreement for what is considered normal range of motion values.
• It doesn’t measure the degree of hypermobility.

One strength of the BS is that there is a high degree of reliability among those doing the measurements – they are consistent between different people measuring and or one person doing multiple measurements (1).

Dr. Alexander concluded that there is currently too much variability in studies published on the Beighton Score to conclude validity. There is no standardization in how it was used, there were different cut-off ranges, and some didn’t use the correct tool (goniometer), there were differences in reporting methods and statistics, and there was no standardized use of terms to even describe hypermobility and more (1).

She suggests the Beighton Score not be used to rule out a diagnosis of GJH – if you don’t score high on the scale, it doesn’t mean you don’t have GJH if other symptoms are pointing to that diagnosis. If a patient scores less than 4, they should still be assessed for clinical signs of connective tissue disorders (1).

Ultimately, more research is needed. Unrecognized or undiagnosed hypermobility disorders can be quite harmful, leading to a lack of adequate healthcare and support (2).

Alternative methods for assessing hypermobility

There are other hypermobility assessment tools, such as the Hospital Del Mar/Bulbena Score, The Rotès–Quérol Score, and others, but none have been used as extensively as the Beighton score (1). These two particularly involve more measurements and are more time-consuming, which likely leads to the limited use of these methods (2).

Another tool is the 5-Part Questionnaire (5PQ) developed by Drs. Hakim and Grahame, which was developed as a tool to identify symptomatic hypermobility (7, 8). A positive answer to 2 or more questions suggests generalized joint hypermobility.

The 5 Part Questionnaire (5PQ)

1. Can you now (or could you ever) place your hands flat on the floor without bending your knees?
2. Can you now (or could you ever) bend your thumb to touch your forearm?
3. As a child, did you amuse your friends by contorting your body into strange shapes, OR could you do the splits?
4. As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?
5. Do you consider yourself double-jointed?

Two other tools that are used include the Upper limb and lower limb assessments. According to the Ehlers-Danlos Society, these two are being assessed by the hEDS/HSD Working Group of the International Consortium on Ehlers-Danlos syndromes and hypermobility spectrum disorders. The goal is to see if they can improve hypermobility diagnostics by including other joints not covered in the Beighton score.

Symptoms associated with joint hypermobility syndromes

There is a wide range of symptoms that extend beyond joint hypermobility. These symptoms do impact multiple body symptoms, which can make diagnosis and management more complex. People may have symptoms such as

• Widespread joint and musculoskeletal pain
• Joint instability, including subluxations and dislocations
• Fatigue – sometimes chronic fatigue syndrome
• Soft tissue injuries and strains
• Exercise intolerance
• Dysautonomia like POTS and other autonomic nervous system dysregulation
• GI issues like bloating, pain, constipation, reflux
• Neurological issues like headaches, migraines, nerve compression syndromes
• Cognitive issues like brain fog
• Anxiety

This is not an exhaustive list – this is just an example of how complex a patient can be.   When reading this list, it can become clearer why we cannot rely just on the Beighton Score to diagnose and assess systemic connective tissue diseases.

Here is a video I made to bust some myths surrounding diagnosis – have you heard the “there’s no need to get an EDS diagnosis because there is no cure”? Here, I bust some of these myths.

FAQs

What Beighton score indicates hypermobility?

According to the current diagnostic criteria published in 2017, a score of greater or equal to 5 in adults post puberty to age 50. After the age of 50, a score of greater than or equal to 4 is suggested to indicate generalized joint hypermobility.

What is considered a normal Beighton score?

A score of 0 would indicate no hypermobility – in the joints tested. A score of less than 5 may indicate localized joint hypermobility – for instance, just in the elbows.

Can the Beighton score be used for children?

There is some controversy surrounding cut-off scores for children because hypermobility naturally decreases with age. The current recommendation from the 2017 diagnostic criteria is a score of greater or equal to 6 in children before puberty and adolescents.

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.