Hospital Del Mar Criteria

Original Editor - Angeliki Chorti

Top Contributors - Angeliki Chorti and Uchechukwu Chukwuemeka

Introduction[edit | edit source]

The Hospital Del Mar criteria is a screening and clinical rheumatological tool that could serve as an alternative to the Beighton test for hypermobility assessment. Joint hypermobility (JH) or joint laxity refers to the larger than normal range of motion (ROM) during passive or active joint movements of an individual's synovial joints. [1] Generalised joint hypermobility (GJM) involves several joints, and occurs as an asymptomatic condition attached to various musculoskeletal and extra-musculoskeletal manifestations, relatively frequently in the general population; however, GJH is also present in various hereditary connective tissue disorders, such as the Ehlers Danlos syndrome (EDS). [2]

To date, diagnosis of hypermobility is generally based on clinical judgement because there is no universal gold standard of diagnostic criteria for the condition.

Objective[edit | edit source]

To assess general passive joint hypermobility.

Intended Population[edit | edit source]

The Hospital Del Mar criteria have been mainly used in paediatric populations. Screening and clinical rheumatological settings may be more suitable for this type of testing. [3]

Method of Use[edit | edit source]

The Hospital Del Mar test assesses the degree of hypermobility in passive movement in the following joints: [4]

  1. little finger,
  2. thumb,
  3. elbow,
  4. shoulder rotation,
  5. hip,
  6. knee extension and flexion,
  7. patella,
  8. ankle
  9. metatarsal-phalangeal joint
  10. and, in some versions, trunk mobility i.e. forward flexion to the floor (stretched legs)

The test is performed bilaterally, but only one point is given, regardless if the result is bi- or unilateral hypermobility. The maximum score is ten(10) points. [5]

Hospital Del Mar criteria for the assessment of joint hypermobility [3]
Upper Extremities 1. Thumb: Passive apposition of the thumb to the flexor of the forearm at ˂21 mm

2. Metacarpophalangeal: With the palm resting on the table, the passive dorsiflexion of the fifth finger is ≥90°

3. Elbow hyperextension: The passive extension of the elbow is ≥ 10°

4. External shoulder rotation: With the upper arm touching the body and with the elbow at 90°, the forearm is taken in external rotation ≥ 85° of the sagittal plane (shoulder-to-shoulder line).

Lower Extremities Supine Position:

5. Hip abduction: The passive hip abduction can be taken to an angle of ≥ 85°

6. Patellar hypermobility: With one hand holding the proximal end of the tibia, the patella can be moved well to the sides with the other hand

7. Ankle and feet hypermobility: An excess range of passive dorsiflexion of the ankle and eversion of the foot can be produced

8. Metatarsophalangeal: Dorsal flexion of the toe of the foot over the diaphysis of the first metatarsal is ≥ 90°

Prone Position:

9. Knee hyperflexion: Knee flexion allows the heel to make contact with the buttock

Ecchymoses 10. Ecchymoses: Appearance of ecchymoses after hardly noticed, minimal traumatism

Evidence[edit | edit source]

The Hospital del Mar criteria have been used with the Beighton test to supplement the shoulder, hip, knee flexion, patella, ankle and metatarsophalangeal hypermobility joint assessment. [3] Validity and reliability are considered high. [3] [5] Kappa coefficients were greater than 0.81 in a study done in children sample[5]. However, the use of some of the Hospital del Mar criteria resulted in high values in knee hyperflexion (78–100%) and external shoulder rotation (67–95%), and this may suggest that the limit values for these motions might be within “normal” in children (5-8 years old). As a result, these criteria may be inappropriate for hypermobility in children. [4]The same may apply to trunk assessment since some authors consider heel-to-buttock movement as the same as knee hyperflexion. [4] It is also argued that the cut-offs and scoring system for the Hospital del Mar criteria ought to change (e.g. give one point for each joint instead of giving one point regardless of bi- or unilateral hypermobility results). [4]

Although some support that arthralgia may present later in hypermobility-related problems, there is no clear evidence that diagnostic criteria are associated with hypermobility-related problems. Reference values for hypermobility in infants and preschool children need further investigation when determining specific cut-offs for younger ages and ethnic groups. [5] No high-quality studies exist regarding the effects of existing treatments. Hypermobility may be associated with osteoarthritis but it remains unproven by scientific research. [6]

Links[edit | edit source]

Hypermobility Masterclass by JV Simmonds

References[edit | edit source]

  1. Bird H. Joint hypermobility. Musculoskeletal Care. 2007; 5 (1): 4-19.
  2. Glans MR, Thelin N, Humble MB, Elwin M, Bejerot S. The Relationship Between Generalised Joint Hypermobility and Autism Spectrum Disorder in Adults: A Large, Cross-Sectional, Case Control Comparison. Front Psychiatry. 2022 Feb 8;12:803334.
  3. 3.0 3.1 3.2 3.3 Bulbena A, Duro JC, Porta M, Faus S, Vallescar R, Martin-Santos R. Clinical assessment of hypermobility of joints: assembling criteria. J Rheumatol 1992; 19: 115-22.
  4. 4.0 4.1 4.2 4.3 Öhman A, Westblom C, Henriksson M. Hypermobility among school children aged five to eight years: the Hospital del Mar criteria gives higher prevalence for hypermobility than the Beighton score. Clinical and Experimental Rheumatology 2014; 32: 285-90.
  5. 5.0 5.1 5.2 5.3 Bevilacqua D, Maillard S, Ferrari J. Measuring Joint Hypermobility Using the Hospital Del Mar Criteria - A Reliability Analysis Using Secondary Data Analysis. Archives of Rheumatology & Arthritis Research 2019; 1(1):1-6.
  6. Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature. J Rheumatol. 2007 Apr;34(4):804-9.