This article is part of our comprehensive guide to hypermobility and Ehlers-Danlos syndrome.
Somebody has probably told you your elbows are double jointed, most likely while pulling a face at them. It isn’t a medical term and it never has been, and what it usually describes is an elbow that carries on past straight, so the forearm ends up sitting behind the line of the upper arm. That’s hyperextension, and it’s one of the nine things on the screening score that gets used to work out whether somebody is hypermobile all over [1]. So it’s one item, which isn’t a diagnosis, and on its own it isn’t really a reason to worry about anything either.
What actually decides whether it means anything is a set of three questions sitting underneath it. Is it only the elbows, or does the rest of you do the same thing. Are the joints genuinely causing you any trouble, or are they simply flexible. And is there anything wider going on that would put this into hypermobility spectrum disorder or hypermobile Ehlers Danlos syndrome territory, rather than into the ordinary range of how human beings are built [2].
For a great many people the honest answer stops at the first question, as flexible elbows on their own are a trait, a fairly common one at that, and plenty of people who have them go their whole lives without it costing them anything.
What “Double Jointed” Actually Means
Nothing is doubled, obviously. There’s one elbow in there, built the same way as everybody else’s, with the same bones and the same ligaments sitting in the same places, and what differs is simply how far it travels before something stops it.
That end point is set partly by the shape of the bone at the back of the joint, and partly by the tension in the ligaments and the capsule wrapped around it. Where that connective tissue is more compliant, the end of the range arrives later, so the forearm keeps travelling past the point where most people’s would have stopped. Hence the party trick, and hence the face people pull at it.
Most people find out about it second hand. Somebody spots it while you’re holding a mug or carrying a tray, or a photograph catches an arm at an angle that makes everybody else wince, and from that point on it becomes a thing about you. It’s an odd way to learn something about your own body, and it’s a large part of why people arrive at this question in their thirties having genuinely never thought about it before.
The reason the phrase is worth retiring isn’t pedantry, it’s that “double jointed” flattens three separate questions into one word. It says nothing about how much of you does it, it says nothing about whether it hurts, and it says nothing about whether there’s anything else going on [2]. Those three have genuinely different answers though, and the everyday use of the phrase buries the lot of them.
The Elbow Is One of Nine Beighton Items
The Beighton score is the screen nearly everybody starts with, and it’s five movements scored out of nine. Little fingers bending back on each hand, thumbs folding down towards the forearm on each side, elbows going past straight, knees going past straight, and then a forward bend with the palms flat on the floor [1]. Four of the tests get done on both sides, which is where the total comes from, and most of the score sits in the hands and the arms [1].
It takes about thirty seconds to do, which is either its great strength or its great weakness, depending a fair bit on who’s holding the goniometer (a protractor for joints, essentially).
You can run through it yourself at a kitchen table, and plenty of people do. Push the little finger of one hand back towards the wrist and see whether it travels past a right angle, then pull the thumb of the same hand back towards the forearm and see whether it reaches. Straighten the elbow out and have a look at it side on. Stand up, lock the knees and look at those side on as well, and then, with the feet together and the knees straight, bend forward and see whether the palms go flat on the floor. One point each, both sides where there are two of them, and the forward bend is the single point that takes the total to nine.
What that gives you is a number, and a number isn’t a diagnosis, as the score was built to flag who’s worth examining properly rather than to hand out labels across a kitchen table [1]. It’s still worth doing though, as it answers the question the elbows can’t answer on their own, which is whether they’ve got company.
Now, the elbow is the item that turns up most often. Among school aged children in Saudi Arabia, the elbow was the commonest hypermobile joint on the whole score, turning up in roughly one child in six [3]. So a flexible elbow isn’t an unusual finding at all, it’s the single most ordinary finding on the score. Which means one positive item, on the item most likely to be positive, tells you very nearly nothing by itself.
None of which is an argument for ignoring it, it’s an argument for going and having a look at the other eight.
One Flexible Elbow, or Flexible All Over
Generalised joint hypermobility means enough joints across the body move beyond the usual range to clear the threshold on the score, and isolated means one joint, or one region, does it while the rest of you doesn’t. That distinction runs straight through every label that follows.
Hypermobility spectrum disorder, which everybody shortens to HSD, is the term for hypermobility that’s genuinely causing problems in somebody who doesn’t meet the criteria for hypermobile Ehlers Danlos syndrome, and it comes in four forms depending on where the looseness actually sits [4]. Generalised is for the person who clears the threshold on the score and has the symptoms to go with it. Peripheral is the hands and feet version, so fingers and toes rather than the whole body. Localised covers one joint or a small cluster of them. And historical is the one for somebody whose joints used to be loose and aren’t any more, which happens more often than people expect.
Localised is the one that matters if you’re here about your elbows, as it’s the category for a couple of joints rather than a whole body, and it’s a real diagnosis rather than a consolation prize for not scoring highly enough. People with the localised and the historical forms, report much the same symptoms, and much the same other conditions alongside them, as people with the generalised form and people with hEDS [5]. Which is a fairly strong argument against reading the four forms as a ranking.
So, the number of boxes you tick matters a good deal less than whether the joints are actually doing you any harm.
Flexible With Symptoms, and Flexible Without
Asymptomatic joint hypermobility means the joints move further than usual and aren’t currently causing you any musculoskeletal trouble that you could put down to the laxity. Symptomatic means they are: pain, instability, soft tissue injuries that keep coming back, or joints that sublux and dislocate [6].
A lot of those with hypermobility sit firmly in the first group, and the evidence on that is reasonably consistent. In a group of healthy college students, the ones with generalised hypermobility reported no more symptoms than the ones without it. The ones who met the older symptomatic syndrome label were a different story entirely, as they reported more sprains, more back pain, more stress fractures, more clumsiness, easier bruising and worse balance [7]. Same trait, in other words, and two completely different experiences of living with it. Among UK adults, hypermobility does line up with disabling musculoskeletal pain, but only modestly [8]. That modest size is the interesting part though, as it fits a picture where a lot of those with hypermobility go through life without much bother at all, and a smaller group carries nearly all of the trouble.
Now, asymptomatic doesn’t mean guaranteed fine forever. Hypermobility with no current symptoms can still change how you load things, can feed repetitive use injuries, and can become symptomatic later in life [6]. So it’s worth knowing about, and it’s worth being sensible with, particularly if you’ve noticed your elbows going past straight every time you push up out of a chair.
It doesn’t run the other way either. Flexible joints in children and young adults are common enough in the general population, that treating every single one of them as a disorder would flag an enormous number of people who are perfectly fine [9]. That sort of over calling does real harm as well, it just doesn’t look like harm, as nobody ever writes the article about the child who got told she had a connective tissue disorder and didn’t.
There’s a version of this that gets used against people though. Being told “you’re just flexible”, as though the flexibility were the finding and the pain were an opinion, happens a great deal in this community, and the asymptomatic and symptomatic split is exactly the thing that sentence walks straight past. Flexible is the trait, and whether it’s costing you anything is a separate question entirely, with its own answer.
HSD, hEDS, and the Line Between Them
hEDS is the narrower of the two labels and the more syndromic one. It asks for generalised joint hypermobility plus a set of wider features, and it’s diagnosed on the clinical picture alone, as it’s the one Ehlers Danlos subtype with no confirmatory molecular test behind it [10].
HSD is the label for hypermobility that’s clinically significant and symptomatic, where the full hEDS criteria aren’t met and no other heritable or acquired condition explains the presentation better [11].
That’s the textbook version and it reads beautifully, though in an actual clinic it’s considerably less tidy.
In one clinic group, the people diagnosed with hEDS had more objective connective tissue signs, more family history, more pain, more bleeding and slightly higher scores than the people diagnosed with HSD [12]. Elsewhere, most of the reported symptoms and most of the other conditions turn out much the same across both groups, and in places the HSD group reported more symptoms than the hEDS one [13]. Those two don’t point in the same direction. HSD is not mild hEDS by definition, whatever the shape of the two names might suggest, even though plenty of people and plenty of clinicians do experience them as neighbours [13].
And the labels move about on the same person. Among a large group of people answering questions about their own diagnosis, roughly half of those carrying an HSD label met the hEDS criteria when their answers were checked against them, and a sizeable minority of those carrying an hEDS label turned out not to [14]. Which is a polite way of saying that which of the two you end up with depends a fair bit on who you happened to see.
None of that makes either label meaningless. It does mean that if you’ve been given one and somebody else with an almost identical history has been given the other, nobody has necessarily made a mistake, and you haven’t been fobbed off with the lesser version of anything.
That matters practically as well as emotionally, as a lot of people spend a considerable amount of energy trying to get their label upgraded, on the understanding that the other one is the serious one and this one is the brush off. On the evidence though, that energy is better spent elsewhere.
How Anybody Actually Gets Diagnosed
The starting point is the Beighton score, and the threshold moves with age, because range of movement generally drops as people get older [15].
– Children and teenagers: Six points or more. The bar sits deliberately higher for children, as a lower one classifies an enormous number of perfectly ordinary children as hypermobile, and paediatric guidance is firm about it for that reason [16].
– Adults up to the age of fifty: Five points. This is the cut off most adults will have been scored against, and it’s been gone back over since, to check whether it sits in the right place [17].
– Adults over fifty: Four points. Range drops with age, so a threshold that ignored that would quietly write off everybody past a certain birthday.
Clearing the threshold is only the first of three things hEDS asks for though. The second is at least two out of a group of three: systemic features of a connective tissue disorder, a family history, or musculoskeletal complications such as chronic pain and recurrent dislocations. The third is exclusion, so other heritable and acquired connective tissue disorders have to have been ruled out, and nothing else can explain the picture better [15].
HSD is what’s left when the hypermobility is symptomatic, the other causes have been excluded, and the hEDS criteria aren’t met [18].
Genetic testing has a part in that third step, and it isn’t the part most people expect: there’s no test that confirms hEDS. What testing does is rule out the other connective tissue disorders, or turn up an alternative diagnosis where the presentation looks atypical or more syndromic than hEDS usually does [19]. Candidate genes and plasma markers are being looked at, and a gene involved in matrix remodelling has recently been put forward, but it still needs independent validation before it changes anything in a clinic [20].
So, if somebody has offered you a genetic test that will tell you whether you have hEDS, they’ve either misunderstood what the test does, or they’re selling you something.
What the Beighton Score Misses
The score was built as a screen and it behaves like one, as it samples only a handful of joints and leans heavily on the hands and the arms [1]. Which means it can miss hypermobility that matters clinically in joints it never tests at all, including some fairly large ones [21]. A hip, a shoulder or a jaw that causes somebody daily grief, contributes precisely nothing to the number.
More detailed tools do exist. There’s an upper limb assessment that goes well beyond the little fingers, thumbs and elbows, and a lower limb one doing the same job for the legs [22][23]. Both are adjuncts rather than replacements though, as the diagnostic criteria still run on the Beighton score, so a high score on one of those won’t get you across a threshold on its own.
The other thing a score misses is time. Hypermobility tends to reduce with age, and it can drop off after an injury or after surgery, so somebody with an unmistakable history of loose joints, can measure below the threshold on the day she’s assessed [15]. If you were the child who could put your palms flat on the floor without bending your knees, and now can’t get past your shins, that history isn’t irrelevant, it’s evidence.
Which is exactly why the questions about your past matter as much as the examination does, and why a five point questionnaire about how flexible you used to be gets used when a score lands one point short of the threshold [15]. It is an imperfect instrument, mind. In some groups it does a better job of ruling generalised hypermobility out than of confirming it [24].
That doesn’t make the score useless, it makes it a screen, and a screen is a thing you use to decide who to look at properly. The criteria built on top of it are both widely used and widely criticised as stringent and imperfect [25], which is worth knowing if you’ve been assessed and come out the other side without a label you were fairly sure you’d get.
What to Take From Flexible Elbows
If your elbows travel back past straight and nothing hurts, nothing gives way and nothing keeps getting injured, what you’ve got is a trait. A common one at that, in fact the commonest single finding on the entire screening score, and not a diagnosis sitting in a waiting room [3].
If they travel back past straight and you’re also dealing with pain, joints that give way, injuries that keep returning, or the same story playing out in your fingers, your knees and your shoulders, that’s a different conversation entirely. One worth having with somebody who knows the criteria properly, rather than somebody who glances at your hands.
The useful question was never how far the elbow goes. It’s whether the hypermobility is isolated or generalised, whether it’s causing you symptoms, and whether there’s anything wider going on that fits HSD or the narrower hEDS [11]. Take the history with you when you go, including the bits about what you could do as a child, because that’s the part most likely to get missed and the part you’re the only witness to.
And if you do come away with one of the labels, keep in mind how much the two of them overlap, as the difference between them can come down to who assessed you rather than to anything your joints are doing [14].
The Fibro Guy
References
[1] Malek, S., Reinhold, E.J. and Pearce, G.S. (2021) ‘The Beighton Score as a measure of generalised joint hypermobility’, Rheumatology International. https://doi.org/10.1007/s00296-021-04832-4
[2] Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F. and 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. https://doi.org/10.1002/ajmg.c.31539
[3] Sirajudeen, M.S., Waly, M., Alqahtani, M., Alzhrani, M., Aldhafiri, F., Muthusamy, H. et al. (2020) ‘Generalized joint hypermobility among school-aged children in Majmaah region, Saudi Arabia’, PeerJ. https://doi.org/10.7717/peerj.9682
Read More[4] Atwell, K., Michael, W., Dubey, J., James, S., Martonffy, A., Anderson, S. et al. (2021) ‘Diagnosis and Management of Hypermobility Spectrum Disorders in Primary Care’, The Journal of the American Board of Family Medicine. https://doi.org/10.3122/jabfm.2021.04.200374
[5] Fairweather, D., Bruno, K.A., Darakjian, A.A., Wilson, F.C., Fliess, J.J., Murphy, E.F. et al. (2025) ‘Localized and historical hypermobile spectrum disorders share self-reported symptoms and comorbidities with hEDS and HSD’, Frontiers in Medicine. https://doi.org/10.3389/fmed.2025.1594796
[6] Tinkle, B.T. (2020) ‘Symptomatic joint hypermobility’, Best Practice & Research Clinical Rheumatology. https://doi.org/10.1016/j.berh.2020.101508
[7] Russek, L.N. and Errico, D.M. (2015) ‘Prevalence, injury rate and, symptom frequency in generalized joint laxity and joint hypermobility syndrome in a “healthy” college population’, Clinical Rheumatology. https://doi.org/10.1007/s10067-015-2951-9
[8] Mulvey, M.R., Macfarlane, G.J., Beasley, M., Symmons, D.P.M., Lovell, K., Keeley, P. et al. (2013) ‘Modest Association of Joint Hypermobility With Disabling and Limiting Musculoskeletal Pain: Results From a Large‐Scale General Population–Based Survey’, Arthritis Care & Research. https://doi.org/10.1002/acr.21979
[9] Tofts, L.J., Simmonds, J., Schwartz, S.B., Richheimer, R.M., O’Connor, C., Elias, E. et al. (2023) ‘Pediatric joint hypermobility: a diagnostic framework and narrative review’, Orphanet Journal of Rare Diseases. https://doi.org/10.1186/s13023-023-02717-2
[10] Malfait, F., Francomano, C., Byers, P., Belmont, J., Berglund, B., Black, J. et al. (2017) ‘The 2017 international classification of the Ehlers–Danlos syndromes’, American Journal of Medical Genetics Part C: Seminars in Medical Genetics. https://doi.org/10.1002/ajmg.c.31552
[11] Morlino, S. and Castori, M. (2023) ‘Placing joint hypermobility in context: traits, disorders and syndromes’, British Medical Bulletin. https://doi.org/10.1093/bmb/ldad013
[12] Aubry-Rozier, B., Schwitzguebel, A., Valerio, F., Tanniger, J., Paquier, C., Berna, C. et al. (2021) ‘Are patients with hypermobile Ehlers–Danlos syndrome or hypermobility spectrum disorder so different?’, Rheumatology International. https://doi.org/10.1007/s00296-021-04968-3
[13] Darakjian, A.A., Bhutani, M., Fairweather, D., Kocsis, S.C., Fliess, J.J., Khatib, S. et al. (2024) ‘Similarities and differences in self-reported symptoms and comorbidities between hypermobile Ehlers–Danlos syndrome and hypermobility spectrum disorders’, Rheumatology Advances in Practice. https://doi.org/10.1093/rap/rkae134
[14] Daylor, V., Griggs, M., Weintraub, A., Byrd, R., Petrucci, T., Huff, M. et al. (2025) ‘Defining the Chronic Complexities of hEDS and HSD: A Global Survey of Diagnostic Challenges, Life-Long Comorbidities, and Unmet Needs’, Journal of Clinical Medicine. https://doi.org/10.3390/jcm14165636
[15] Gensemer, C., Burks, R., Kautz, S., Judge, D.P., Lavallee, M. and Norris, R.A. (2020) ‘Hypermobile Ehlers‐Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes’, Developmental Dynamics. https://doi.org/10.1002/dvdy.220
[16] Williams, C.M., Welch, J.J., Scheper, M., Tofts, L. and Pacey, V. (2024) ‘Variability of joint hypermobility in children: a meta-analytic approach to set cut-off scores’, European Journal of Pediatrics. https://doi.org/10.1007/s00431-024-05621-4
[17] Tofts, L., Pacey, V., Williams, C.M., Welch, J.J., Shannon, B. and Chan, C. (2026) ‘Generalized Joint Hypermobility in Adults: A Systematic Review With Meta‐Analysis to Identify Data‐Driven Cut‐offs Using the Beighton Score’, Arthritis Care & Research. https://doi.org/10.1002/acr.70017
[18] Carroll, M.B. (2023) ‘Hypermobility spectrum disorders: A review’, Rheumatology and Immunology Research. https://doi.org/10.2478/rir-2023-0010
[19] Forghani, I., See, J. and McGonigle, W.C. (2025) ‘Hypermobile Ehlers–Danlos Syndrome: Diagnostic Challenges and the Role of Genetic Testing’, Genes. https://doi.org/10.3390/genes16050530
[20] Gensemer, C., Petrucci, T., Beck, T., Daylor, V., Griggs, M., Griggs, C. et al. (2025) ‘KLK15 alters connective tissues in hypermobile Ehlers-Danlos syndrome’, iScience. https://doi.org/10.1016/j.isci.2025.113343
[21] Ritelli, M., Chiarelli, N., Cinquina, V., Bertini, V., Piantoni, S., Caproli, A. et al. (2024) ‘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’, American Journal of Medical Genetics Part A. https://doi.org/10.1002/ajmg.a.63857
[22] Nicholson, L.L. and Chan, C. (2018) ‘The Upper Limb Hypermobility Assessment Tool: A novel validated measure of adult joint mobility’, Musculoskeletal Science and Practice. https://doi.org/10.1016/j.msksp.2018.02.006
[23] Meyer, K.J., Chan, C., Hopper, L. and Nicholson, L.L. (2017) ‘Identifying lower limb specific and generalised joint hypermobility in adults: validation of the Lower Limb Assessment Score’, BMC Musculoskeletal Disorders. https://doi.org/10.1186/s12891-017-1875-8
[24] Schlager, A., Ahlqvist, K., Pingel, R., Nilsson-Wikmar, L., Olsson, C.B. and Kristiansson, P. (2020) ‘Validity of the self-reported five-part questionnaire as an assessment of generalized joint hypermobility in early pregnancy’, BMC Musculoskeletal Disorders. https://doi.org/10.1186/s12891-020-03524-7
[25] Ritelli, M., Chiarelli, N., Cinquina, V., Vezzoli, M., Venturini, M. and Colombi, M. (2023) ‘Looking back and beyond the 2017 diagnostic criteria for hypermobile Ehlers‐Danlos syndrome: A retrospective cross‐sectional study from an Italian reference center’, American Journal of Medical Genetics Part A. https://doi.org/10.1002/ajmg.a.63426
