If you have Generalised Joint Hypermobility (GJH), you’re not alone – it is a common condition, affecting anywhere from 2% to 57% of people [1]. This large variation in population percentages is due to differences in how Hypermobility diagnosis is done within each study, as well as differences in study populations, methods and criteria used.

While some individuals with Hypermobility experience no discomfort, others may develop various physical and psychological symptoms. In fact, approximately 10% of people with Hypermobility have symptoms that significantly affect their daily lives. When Hypermobility is present without pain or other issues, it is referred to as Asymptomatic Hypermobility. 

So, how is Hypermobility diagnosed? Identifying Hypermobility and Hypermobility Spectrum Disorders (HSDs) requires a thorough clinical evaluation, a detailed patient history, and the application of specific diagnostic criteria.

Since 2017, a revised classification system developed by the International Consortium on the Ehlers-Danlos Syndromes has provided clearer guidelines for diagnosing Hypermobility [2]. This system distinguishes between different types of Hypermobility-related conditions, ensuring a more consistent approach to diagnosis.

• Asymptomatic Hypermobility (with no symptoms)
• Generalised/Peripheral Joint Hypermobility
• Localised Joint Hypermobility

Why is a diagnosis of Hypermobility, Hypermobility Spectrum Disorder (HSD) or EDS controversial?

‍Diagnosing Hypermobility, Hypermobility Spectrum Disorder or Hypermobile EDS (hEDS) can be challenging and at sometimes controversial. This diagnostic challenge is because of the many overlapping symptoms that exist between these conditions as well as the variable and unpredictable presentation of the symptoms that lead to diagnosis [13] [14]. It is the reason for why the EDS Society has been working diligently towards it’s “Road to 2026”. The Road to 2026 is the path and process toward an update of the 2017 International Classification of the Ehlers-Danlos syndromes. The aim of this update is to advance the understanding and management of EDS and HSD on a global scale, reducing the time to diagnosis, and improving care.

Hypermobile EDS (hEDS) lacks a definitive genetic marker, blood test or other biomarker, so its diagnosis is only through carefully honed clinical assessment and exclusion of other related conditions. This has led to debates among health and medical professionals about diagnostic criteria and the classification of symptoms. It takes a trained Hypermobility and/or EDS aware health care professional to truly find if you have or have had Hypermobility and if it is affecting you in a syndromic or “body-wide and life impacting” way.

Experts suggest that doctors should look beyond just the Beighton Score when someone comes in with injuries or joint pain that might be linked to Hypermobility. While detailed assessments of the arms and legs are useful for experienced doctors or researchers, they are complicated and require specialist skills [3].

Key steps and tools used in the Hypermobility diagnosis process

Each person is unique, and Hypermobility, HSD and hEDS do not follow the same pattern or present the same way in any individual which is why looking at more than just a single test is essential to getting the correct diagnosis. Diagnosing Hypermobility involves a combination of physical assessments, patient symptom history, exclusion testing and the meeting of specific criteria.

Screening for Hypermobility – the first step in a Hypermobility diagnosis

Many of my patients know they are extra bendy, however many also comment that “I’ve always been like this and never thought of it as an issue until everything else fell apart.” A Hypermobile or EDS aware healthcare professional can perform a physical examination to assess the range of motion in various joints. This includes seeing how far joints can move beyond the normal range.

Physical Assessment 1

Take the Beighton Scale test:  

The Beighton Score is a test that is widely used tool to measure joint Generalised Joint Hypermobility [3]. It consists of a series of tests that assess the flexibility of the spine, elbows, knees, wrists, and fingers.

Each test is scored, and the total score helps decide the extent of Hypermobility.

The Beighton Score includes:

• Bending the little finger back beyond 90 degrees with your forearm flat on a surface (both pinky fingers) with little force, not overexerting the push.
• Bending the thumb forwards to touch the forearm, so that the palm and thumb move towards the surface of forearm (both thumbs) with little force, not overexerting the push.
• Hyperextension of the elbows and knees beyond 10 degrees, with little force, not overexerting the push.
• Bending forward to place the palms flat on the floor with straight legs.
• Beighton involves a series of physical tests to measure the range of motion in only 4 main joints. Unfortunately, this does not cover all the body’s joints, so it is not truly representative of GJH.
• A total score of 5 or more out of 9 indicates generalised joint Hypermobility in persons under the age of 50, and 4 out of 9 for people over 50. This scoring system helps healthcare professionals assess the extent of joint flexibility and identify potential Hypermobility-related conditions.

Testing for Historical Joint Hypermobility or “The 5-part questionnaire for hypermobility”

The 5-part questionnaire relates to the fact that you may have been Hypermobile in your past or that you have a history of joint dislocations or injuries [7].

When reviewing Historical Joint Hypermobility answering yes to 2 or more of these questions suggests Hypermobility.

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

A point to note:

The Beighton and Historical Joint Hypermobility Test scores are good “general “screening tools for the presence of GJH. However, people often have Hypermobility in joints that are not measured by the Beighton score, such as the jaw, neck, shoulders, pelvis, wrists, hips, ankles, feet, and toes. In these situations, only relying on the either of these scores is not enough [7]. If a person has joint Hypermobility in more than 5 different areas throughout the body this can also be classified as Generalised Joint Hypermobility.

Additional tests for body wide Hypermobility

To help get a clearer sense of whether you are Hypermobile there are other tests that consider the full shoulder and arm, hip, and leg. In some cases, additional tests may be needed to rule out other conditions or to assess the extent of the impact of hypermobility on your body.

There are three other tools that health professionals can use to assess Hypermobility more thoroughly. These Hypermobility diagnosis tools require a detailed examination of many more joints across the body. In the arm this includes the range of motion at the shoulder, elbow, wrist, and fingers. In the leg this includes several ranges of movement at the hip, knee, ankle, heel, and toes.

• One assessment reviews hypermobility in the arm, and was created by Nicholson and colleagues in 2018 [8]
• The other two tests look at hypermobility in the hip, leg, and foot.
• The assessment for children was created by Ferrari and team in 2005 [9]
• The adult lower limb assessment was created by Myer and colleagues in 2017 [10]

If your hypermobility is related to other body wide health issues, signs, and symptoms it may be part of a more complex or serious condition and should be investigated by your health care providers.

How is Hypermobility Spectrum Disorder (HSD) diagnosed?

HSD can be diagnosed by a hypermobile aware clinician (allied health or medical professional), through taking a thorough medical history and completing a physical examination. In the process, clinicians need to rule out other conditions that can cause the same symptoms, including hEDS. To be diagnosed with HSD, there should be evidence that the joint hypermobility is causing problems and affecting the life of the individual, and it is not just an asymptomatic feature, non-problematic sign [11]. These signs and symptoms can include:

These problems include muscle and joint related issues such as:  

• Joint subluxations and/or dislocations
• Joint pain and loss of joint function
• Joint damage, such as cartilage tear
• Early joint degeneration (which may, over time, lead to significant wear and tear called osteoarthritis)
• Soft tissue (ligament/tendon) damage and injury
• Recurrent, persistent, and/or chronic pain
• Poor proprioception (reduced awareness of body’s position/movement)

Other body wide symptoms that often occur in people with HSD include:  

• Fatigue
• Autonomic dysfunction
• Headaches
• Gastrointestinal problems
• Anxiety disorders
• Fibromyalgia
• Gastrointestinal dysfunction – diarrhoea, nausea, vomiting, food intolerances-constipation
• Dysautonomia including Postural Orthostatic Tachycardia Syndrome (POTS) – dizziness, pre-fainting, gut symptoms, fatigue, and fainting.
• Depression
• Gynaecological and or Bladder issues
• Mast cell activation syndrome (MCAS) /Allergies/Anaphylaxis
• Neurodivergence- ADHD-ADD-Autism-ASD-Dyslexia-Dyspraxia-OCS-Tourette Syndrome

Types of Hypermobility Spectrum Disorders

• Generalised Hypermobility Spectrum Disorder
• Peripheral Hypermobility Spectrum Disorder
• Localised Hypermobility Spectrum Disorder
• Historical Hypermobility Spectrum Disorder

Signs and symptoms that Hypermobility is part of a larger or more complex condition – Hypermobile Ehlers Danlos Syndrome (hEDS)

When you have multiple health symptoms that are affecting your life in addition to Hypermobility, hEDS should also be considered as a possibility. hEDS diagnosis requires the meeting of the 2017 International criterial for hEDS and needs to be undertaken by a medical practitioner. The summary below of the 2017 International Classification of hEDS outlines the criteria for diagnosing Hypermobile EDS.

This assessment involves meeting certain criteria and includes the review by a medical practitioner of a variety of symptoms and careful family history, including assessment for:

• Generalised Joint hypermobility and/or Historical Joint Hypermobility (Beighton score and 5-part questionnaire), plus, at least five of the below signs/symptoms including:
  • Unusually soft velvety skin
  • Slightly more stretchy skin than most people
  • Unexpected stretch marks or striae
  • Atrophic (thin and/or broad) scarring and or poor wound healing
  • Bumpy bubbly skin across the heels or feet-piezogenic papules
  • Abdominal hernias (when an organ or tissue pushes through a weak spot in the skin, often appearing as a noticeable lump or bulge)
  • Rectal/bladder or other prolapse- when these organs/tissues move and or slip out of place.
  • Dental crowding (overlapping of teeth) or a narrow high palate
  • Arachnodactyly – longer than usual fingers and thumbs
  • Thin tall build with longer limbs than most people (arm span: height ratio greater than 1.05)
  • Heart Valve issues and or Aorta issues (both would need a heart scan to diagnose these conditions)
• Identifying if other family members have HSD, hEDS or EDS.
• Symptoms that are chronic (lasting longer than 3 months), especially in terms or muscle or joint pain, and joint instability.
• Exclusion of other disorders and conditions with similar symptoms.

For further information see the articles on this site:

• How is Ehlers Danlos Syndrome (EDS) diagnosed?
• Step-by-step guide to diagnosing Hypermobile Ehlers-Danlos Syndrome (hEDS)

“Red Flags” or Signs that you may need referral to a specialist

Before a diagnosis of hEDS, HSD or GJH is given It is essential for the clinician to exclude other conditions with greater risk of severe health conditions or syndromes. Indications for further investigation or referral to a specialist in the presence of joint hypermobility includes checking:

Do you currently have…

• Blue sclera: The whites of your eyes may look bluish.
• Tall or short stature: You might be noticeably taller or shorter than average.
• Cardiac murmurs: You could have unusual sounds in your heart that a doctor can hear with a stethoscope.
• Skin fragility: Your skin might be delicate and easily split or be damaged.
• Lens dislocation: The lens in your eye can move out of place.
• High myopia: You might be very nearsighted, making distant objects look blurry.
• Ectopic lentis: The lens in your eye is not in the normal position.
• Developmental disability: You may face challenges in development, such as learning or physical growth.
• Intellectual disability: You might have difficulties with intellectual tasks and problem-solving.
• Dysmorphic features: Your facial features could look different from the typical shape and structure.
• Cleft palate/bifid uvula: You might have a split in the roof of your mouth or a uvula (the dangly bit at the back of your throat) that looks split.
• Multiple congenital anomalies: You could have several birth defects present at birth.
• Marfanoid body habitus: Your body might have features similar to those seen in Marfan syndrome, such as long limbs and fingers.

Have you ever had…

• Cardiac valve disease: Problems with the heart valves, which can affect how blood flows through the heart.
• Congenital heart disease: Heart defects that you are born with.
• Vascular rupture or dissection: When a blood vessel tears, which can be extremely dangerous.
• Low-force fractures (two in children): Breaking bones easily, even from minor injuries, especially in children and adolescence.
• Talipes equinovarus: Known as clubfoot, where your foot is twisted out of shape or position.
• Severe scoliosis: A significant curvature of the spine.
• Wide atrophic scars: Large, sunken scars that do not heal well.
• Poor wound healing: Your cuts and injuries might take a long time to heal, and stitches may not stay in place.
• Aortic dilatation on echocardiography: The main artery from your heart (aorta) is wider than normal, as seen on an ultrasound.
• Hernia in childhood or recurrent hernia: Frequently developing hernias, where an organ pushes through a weak spot in your muscles.
• Organ rupture: When an organ tears or bursts, which can be extremely serious.
• Recurrent pneumothoracies: Frequently having collapsed lungs.

Do you have a family history of…

• Cardiac valve disease: Problems with the valves in your heart that can affect how blood flows.
• Congenital heart disease: Heart defects that you are born with.
• Vascular rupture or dissection: When a blood vessel tears, which can be very dangerous.
• Mitral valve prolapse: A condition where one of your heart valves does not close properly.
• Sudden unexplained death: Unexpected death with no obvious cause.
• Low-force fractures (three in adults): Breaking bones easily, even from minor injuries, especially if it happens three times or more in adults.
• Formally diagnosed early onset osteoporosis: Being officially diagnosed with weak bones at an early age.
• Aortic dilatation on echocardiography: The main artery from your heart (aorta) is wider than normal, as seen on an ultrasound.
• Organ rupture: When an organ tears or bursts, which can be extremely serious.
• Recurrent pneumothoracies: Frequently having collapsed lungs.

Paediatric diagnosis of Hypermobility Spectrum Disorders

Recently, there have been new advancements in diagnosing Hypermobility Spectrum Disorders in children and teens. Since their symptoms and physical development can be different from adults, experts have created a special diagnostic framework just for them. The Paediatric Working Group of the International Consortium on Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) created criteria that look at things like joint Hypermobility, skin and tissue problems, muscle and bone issues, gut and other broader body system issues and other related conditions.

This framework breaks down kids into different subgroups based on their symptoms and characteristics, helping doctors diagnose them more accurately and provide tailored care. For example, a Beighton score of 6 or higher out of 9 is used to identify kids with Generalised Joint Hypermobility, and additional criteria check for skin involvement, muscle and bone complications, and other related conditions. This approach ensures that kids get the right care and support, improving their quality of life and long-term outcomes.

Delays in getting the correct diagnosis

Delays in getting a diagnosis can have a severe impact on a person’s life. It can lead to financial strain, unnecessary medical tests, treatments that do not work well, and worsening symptoms. Many people struggle to manage their pain, find it hard to keep up with daily activities or school, and may not be as active as they should be. Ongoing pain, unstable joints, and issues with the nervous system can make people afraid to move too much, which can lead to even more fatigue. Giving a patient a working diagnosis and reassuring them that their symptoms are real can help them and their family focus on managing the condition, breaking this cycle [8].

A Clinician’s guide to Hypermobility Syndromes has been created by the Hypermobility Syndrome’s Association and can be found here.

References

[1] Blajwajs, L., Williams, J., Timmons, W. et al. Hypermobility prevalence, measurements, and outcomes in childhood, adolescence, and emerging adulthood: a systematic review. Rheumatol Int 43, 1423–1444 (2023). https://doi.org/10.1007/s00296-023-05338-x

[2] Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F., & Hakim, A. (2017). A framework for the classification of joint hypermobility and related conditions. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), 148-157.

[3] The Ehlers-Danlos Society. (2022). Assessing joint hypermobility. Retrieved from https://www.ehlers-danlos.com/assessing-joint-hypermobility/

[4] Hypermobility Syndromes Association. (n.d.). Hypermobility Disorders: A Clinician’s Guide. Retrieved from https://www.hypermobility.org/_files/ugd/518d8c_70c5473577c84eb98cad62d28bef0f81.pdf.

[5] Beighton P, Solomon L, Soskolne CL (1973) Articular mobility in an African population. Ann Rheum Dis 32(5):413–418

[6] Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. Int J Clin Pract. 2003;57:163–6.

[7] Glans, M., Humble, M.B., Elwin, M. et al. Self-rated joint hypermobility: the five-part questionnaire evaluated in a Swedish non-clinical adult population. BMC Musculoskelet Disord 21, 174 (2020). https://doi.org/10.1186/s12891-020-3067-1

[8] Nicholson LL, Chan C. The Upper Limb Hypermobility Assessment Tool: A novel validated measure of adult joint mobility. Musculoskelet Sci Pract. 2018 Jun;35:38-45. doi: 10.1016/j.msksp.2018.02.006. Epub 2018 Feb 22. PMID: 29510315.

[9] Ferrari J, Parslow C, Lim E, Hayward A. Joint hypermobility: the use of a new assessment tool to measure lower limb hypermobility. Clin Exp Rheumatol. 2005 May-Jun;23(3):413-20. PMID: 15971435. https://europepmc.org/article/MED/15971435

[10] Meyer, K.J., Chan, C., Hopper, L. et al. Identifying lower limb specific and generalised joint hypermobility in adults: validation of the Lower Limb Assessment Score. BMC Musculoskelet Disord 18, 514 (2017). (Free to download)

[11] The Ehlers-Danlos Society. (n.d.). What is HSD? Retrieved April 1, 2025, from https://www.ehlers-danlos.com/what-is-hsd/

[12] Nicholson, L. L., Chan, C., Tofts, L., & Pacey, V. (2022). Hypermobility syndromes in children and adolescents: Assessment, diagnosis and multidisciplinary management. Australian Journal of General Practice, 51(6). https://doi.org/10.31128/AJGP-03-21-5870

[13] Anderson, L. K., & Lane, K. R. (2022). The diagnostic journey in adults with hypermobile Ehlers–Danlos syndrome and hypermobility spectrum disorders: A synthesis of qualitative literature. Journal of the American Association of Nurse Practitioners, 34(4), 639–648. https://doi.org/10.1097/JXX.0000000000000672

[14] Ritelli M, Chiarelli N, Cinquina V, Bertini V, Piantoni S, Caproli A, Della Pina SEL, Franceschini F, Zarattini G, Gandy W, Venturini M, Zoppi N, Colombi M. Bridging the Diagnostic Gap for Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders: Evidence of a Common Extracellular Matrix Fragmentation Pattern in Patient Plasma as a Potential Biomarker. Am J Med Genet A. 2025 Jan;197(1):e63857. doi: 10.1002/ajmg.a.63857. Epub 2024 Sep 3. PMID: 39225014.