The Beighton Score: How to Assess Joint Hypermobility for EDS and HSD

The Beighton score is a standardized clinical assessment tool used to quantify generalized joint hypermobility — a key diagnostic criterion for hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD). Understanding how the Beighton score is performed, scored, and interpreted is essential for patients seeking an EDS or HSD diagnosis, particularly because many patients are assessed incorrectly or incompletely.

The Nine Beighton Maneuvers

The Beighton score consists of five maneuvers, four of which are bilateral (giving a maximum score of 9):

1. Little Finger Extension (bilateral, 1 point each side)

Passively extend the little finger (fifth digit) backward at the metacarpophalangeal joint. Positive: Extension ≥90° beyond neutral.

2. Thumb Opposition to Forearm (bilateral, 1 point each side)

Passively flex the thumb toward the forearm. Positive: The thumb touches the volar (inner) surface of the forearm.

3. Elbow Hyperextension (bilateral, 1 point each side)

Extend the elbow fully. Positive: Hyperextension ≥10° beyond neutral (the elbow bends backward).

4. Knee Hyperextension (bilateral, 1 point each side)

Extend the knee fully while standing. Positive: Hyperextension ≥10° beyond neutral (the knee bends backward — "genu recurvatum").

5. Forward Trunk Flexion (unilateral, 1 point)

Stand with feet together and bend forward to touch the floor with palms flat. Positive: Palms flat on the floor with knees straight.

Maximum score: 9 points (1 for each bilateral maneuver × 2 sides + 1 for trunk flexion)

Scoring Thresholds

The threshold for "generalized joint hypermobility" varies by age and sex:

These thresholds reflect the fact that joint hypermobility naturally decreases with age, and a lower score in an older patient may still represent significant hypermobility relative to their age group.

Important Limitations of the Beighton Score

It does not capture all hypermobile joints. The Beighton score assesses only 5 joint types. Many EDS/HSD patients have significant hypermobility in joints not assessed by the Beighton score — the jaw (TMJ), shoulders, hips, ankles, and cervical spine. A patient with severe shoulder and hip hypermobility but a Beighton score of 3/9 may still have hEDS.

It does not capture historical hypermobility. Many EDS patients become less hypermobile as they age due to joint damage, muscle guarding, and pain-avoidance behaviors. The 2017 hEDS diagnostic criteria allow for a "historical" Beighton score — asking patients to report whether they could perform these maneuvers in the past.

It requires proper technique. The maneuvers must be performed passively (the examiner moves the joint, the patient does not actively assist) and measured correctly. Many clinicians perform the assessment incorrectly, leading to false negatives.

A low score does not rule out hEDS. The 2017 hEDS criteria require a Beighton score ≥5/9 (or ≥4/9 with a positive 5-point questionnaire) as one of three diagnostic criteria, but the other two criteria (systemic features of connective tissue disorder and family history/musculoskeletal complications) can partially compensate for a borderline Beighton score.

The 5-Point Questionnaire

For patients whose Beighton score is borderline (one point below threshold), the 5-point questionnaire can substitute:

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. Did you have dislocations of more than one joint, or the same joint more than once?
4. Do you consider yourself double-jointed?
5. As a child, did you amuse your friends by contorting your body into strange shapes, or could you do the splits?

A score of ≥2/5 "yes" answers can substitute for a Beighton score one point below the threshold.

What to Bring to Your Assessment

If you are being assessed for hEDS or HSD, bring photos or videos of your joint hypermobility — particularly joints not assessed by the Beighton score (shoulder, hip, ankle, jaw). Many patients can demonstrate hypermobility more clearly in a relaxed home environment than in a clinical setting where anxiety and muscle guarding may reduce apparent range of motion.