Beighton score

Objective[edit | edit source]

The Beighton score is a popular screening technique for hypermobility. This is a nine–point scale and requires the performance of 5 manoeuvres, four passive bilateral and one active unilateral performance. It was originally introduced for epidemiological studies involving the recognition of hypermobility in populations. Therefore the scale was well suited, being easy and quick to perform in large numbers of people [1]. The criteria of the Beighton score were the first used to recognize hypermobility, and this method has been in use for 30 years. It involves the evaluation of only a few joints. It does not include other involved systems [2][3].

The Beighton score is a modification of the Carter and Wilkinson scoring system (1964) [4]. Because the passive extension of the fingers was too severe, it was replaced by a passive extension of just the little finger beyond 90° with the forearm flat on a table [5].


  1. It samples only a small number of joints for examination so that hypermobile joints outside this selected group will inevitably and invariably be overlooked.
  2. It is an “all-or-none” test. It does not indicate the degree of hypermobility, merely an expression of the widespread nature of its distribution. An alternative scale that offers a wider view of joint laxity (including the shoulder, hip, patella, ankle, foot and toes) is the 10 – point hospital Del Mar criteria (Barcelona) [1]

Etiology[edit | edit source]

The Beighton score has subsequently been used internationally to define generalized joint laxity in all populations and all age groups. Most of the available prevalence studies used different cutoffs, ranging from >3 hypermobile joints to > 6 hypermobile joints of 9 assessed (both thumbs, both little fingers, both elbows, both knees and the trunk), and in some, only the dominant side was assessed. The most frequent choice of cutoff was > 4 hypermobile joints [6]
Beighton and Horan (1969) revised the test to measure joint laxity in people with Ehlers–Danlos syndrome [5].

Clinical Use[edit | edit source]

Components of the Beighton scale [5]:

1. Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90° 1 1
2. Passive apposition of the thumb to the flexor aspect of the forearm 1 1
3. Passive hyperextension of the elbow beyond 10° 1 1
4. Passive hyperextension of the knee beyond 10° 1 1
5. Active forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on the floor 1 1

The first four elements can be given a maximum score of 2, because these are performed bilaterally. The last element is scored with 0 or 1. The maximum score for ligament laxity is 9. A score of 9 means hyperlax. A score of zero is tight. Several researchers appoint a score of 0-3 as normal and 4-9 as representing ligamentous laxity (Al-Rawi et al 1985, Diaz et al 1993, Klemp et al 1984). According to Child (1986), a score of 4 or more out of 9 indicates generalized hypermobility of the joints [5]. The spinal forward flexion criterion differs from the other criteria, in that it measures hamstring flexibility and anatomic proportions to ligamentous laxity [4]. According to the Beighton and Horan criteria, generalized joint laxity is present when four or more of five tests are positive, including contralateral knee hyperextension [6]. There is no universal agreement on a threshold for BJHMS, some researchers use a Beighton scale score of 5/9, other researchers use a score of 6/9 and still others use a modified score of 3/9 [1][7][8][9][10].

Beighton Score.png

Instructions during the performance of the Beighton scale:
1. I will bend your little finger to 90° to the back of your hand
2. I will bend your thumb back on the front of your forearm
3. I am going to bend your elbow backwards
4. I am going to bend your knee backwards
5. Can you put your hands flat on the floor with your knees straight[6]


Evidence of Use[edit | edit source]

Reliability[edit | edit source]

Clinch J et al (2011) showed that the prevalence of hypermobility in UK children is high, possibly suggesting that the Beighton score cutoff of >4 is too low or that this scoring is not appropriate for use in subjects whose musculoskeletal system is still developing. These results provide a platform to evaluate the relationships between the Beighton criteria and key clinical features (including pain), thereby testing the clinical validity of this scoring system in the pediatric population[6]

According to Remvig et al., the Beighton and Horan method for diagnosis of generalized joint laxity showed high kappa values (intraobserver: 0.75; interobserver: 0.78) [12].

Kyndall L. Boyle investigated the intrarater and interrater reliability of the Beighton and Horan Joint Mobility Index for women aged 15 to 45 years. The purpose was to determine the intrarater and interrater reliability of composite BHJMI scores (overall 0-9) and categorized scores (0-2, 3-4, 5-9). The percentage agreement and the Spearman rho for the intrarater and interrater reliability of the composite scores were 69% and 0.86 and 51% and 0.87, respectively. The percentage agreement and the Spearman rho for the intrarater and interrater reliability of the category scores were 81% and 0.81 and 89% and 0.75, respectively. This concluded that the reliability of BHJMI was good to excellent [13][8][9].

Validity[edit | edit source]

Smits – Engelsman et al. evaluated the validity of the Beigthon score as a generalized measure of hypermobility and measured the prevalence of hypermobility and pain in a random population of school-age children between 6 and 12 years. They concluded that no significant differences in the Beighton score for sex in this population and that the Beigton score, when goniometry is used, is a valid instrument to measure generalized joint mobility in children 6 to 12 years. In white children between 6 and 12 years of age, it is recommended that 7/9 be the cutoff for the Beighton score.[14]

Responsiveness[edit | edit source]

There may be a need to devise a new, more specific assessment tool to evaluate joint laxity in the developing musculoskeletal system—one that can be used to identify children at risk of symptoms such as pain and pathology such as connective tissue disease and, as importantly, to reassure those who do not need further medical intervention [6].

Bravo et al. concluded that the Beighton score is insufficient for JHS diagnosis. They recommend that a validated hypermobility criteria set (i.e., the Brighton criteria or the Hospital del Mar criteria) be routinely used in the evaluation of rheumatology patients [2].

According to Schubert-Hjalmarsson et al., pain affects activity and participation in children with HMS. Balance is also increased compared with healthy controls [15].
Fatoye et al. concluded that pain and Quality of Life might form important components of clinical examination for children diagnosed with HMS. These children may benefit from appropriate treatment programmes to alleviate pain intensity and improve quality of life [16].
Engelbert et al concluded that in children with generalized joint hypermobility and hypomobility, the maximal exercise capacity is significantly decreased compared with age- and gender-matched control subjects. The most probable explanation for the reduced exercise tolerance in our patients is deconditioning.[17]

References[edit | edit source]

  1. 1.0 1.1 1.2 Keer R, Grahame R. Hypermobility Syndrome: Recognition and Management for Physiotherapists. Elsevier 2003; p2 – 4
  2. 2.0 2.1 Bravo JF, Wolff C. Clinical study of hereditary disorders of connective tissues in a Chilean population: joint hypermobility syndrome and vascular Ehlers-Danlos syndrome. Arthritis Rheum. 2006 Feb;54(2):515-23. doi: 10.1002/art.21557.
  3. Pasinato F, Souza JA, Corrêa ECR, Silva AMTD. Temporomandibular disorder and generalized joint hypermobility: application of diagnostic criteria. Braz J Otorhinolaryngol. 2011 Jul-Aug;77(4):418-425. doi: 10.1590/S1808-86942011000400003.
  4. 4.0 4.1 Frontera W, Slovik D, Dawson D. Exercise in Rehabilitation Medicine. Sheridan books 2006; p41
  5. 5.0 5.1 5.2 5.3 Alter M. Science of Flexibility. 3rd edition. Sheridan books, 2004; p89
  6. 6.0 6.1 6.2 6.3 6.4 Clinch J, Deere K, Sayers A, Palmer S, Riddoch C, Tobias JH, Clark EM. Epidemiology of generalized joint laxity (hypermobility) in fourteen-year-old children from the UK: a population-based evaluation. Arthritis Rheum. 2011 Sep;63(9):2819-27. doi: 10.1002/art.30435.
  7. Russek LN. Hypermobility syndrome. Phys Ther. 1999 Jun;79(6):591-9.
  8. 8.0 8.1 Quatman CE, Ford KR, Myer GD, Paterno MV, Hewett TE. The effects of gender and pubertal status on generalized joint laxity in young athletes. J Sci Med Sport. 2008 Jun;11(3):257-63. doi: 10.1016/j.jsams.2007.05.005.
  9. 9.0 9.1 Evans AM, Rome K, Peet L. The foot posture index, ankle lunge test, Beighton scale and the lower limb assessment score in healthy children: a reliability study. J Foot Ankle Res. 2012 Jan 9;5(1):1. doi: 10.1186/1757-1146-5-1.
  10. Yazici M, Ataoglu S, Makarc S, Sari I, Erbilen E, Albayrak S, et al. The relationship between echocardiographic features of mitral valve and elastic properties of aortic wall and Beighton hypermobility score in patients with mitral valve prolapse. Jpn Heart J. 2004 May;45(3):447-60. doi: 10.1536/jhj.45.447.
  11. Physiotutors. The Beighton Score | Generalized Joint Hypermobility. Available from:
  12. Remvig L, Jensen DV, Ward RC. Are diagnostic criteria for general joint hypermobility and benign joint hypermobility syndrome based on reproducible and valid tests? A review of the literature. J Rheumatol. 2007 Apr;34(4):798-803.
  13. Boyle KL, Witt P, Riegger-Krugh C. Intrarater and Interrater Reliability of the Beighton and Horan Joint Mobility Index. J Athl Train. 2003 Dec;38(4):281-285.
  14. Smits-Engelsman B, Klerks M, Kirby A. Beighton score: a valid measure for generalized hypermobility in children. J Pediatr. 2011 Jan;158(1):119-23, 123.e1-4. doi: 10.1016/j.jpeds.2010.07.021.
  15. Schubert-Hjalmarsson E, Öhman A, Kyllerman M, Beckung E. Pain, balance, activity, and participation in children with hypermobility syndrome. Pediatr Phys Ther. 2012 Winter;24(4):339-44. doi: 10.1097/PEP.0b013e318268e0ef.
  16. Fatoye F, Palmer S, Macmillan F, Rowe P, van der Linden M. Pain intensity and quality of life perception in children with hypermobility syndrome. Rheumatol Int. 2012 May;32(5):1277-84. doi: 10.1007/s00296-010-1729-2.
  17. Engelbert RH, van Bergen M, Henneken T, Helders PJ, Takken T. Exercise tolerance in children and adolescents with musculoskeletal pain in joint hypermobility and joint hypomobility syndrome. Pediatrics. 2006 Sep;118(3):e690-6. doi: 10.1542/peds.2005-2219.