The assessment of joint laxity was initially introduced to assist in the evaluation of infantile developmental hip dislocation. Carter and Wilkinson (1964) showed that ligamentous laxity of more than three joints (thumb touching the forearm in wrist flexion, finger MCP hyperextension parallel to forearm in wrist extension, elbow and knee hyperextension greater than 10°, and excess ankle dorsiflexion and eversion) was noted in 45 % (33/74) of patients with infantile hip dislocation, but only in 7 % of a control group of local schoolchildren. They also noted that joint hyperlaxity had a strong familial component and demonstrated that hip dislocation was noted in 64 % of patient with a first-degree relative with hip dislocation. Beighton and Horan (1969) expanded upon the Carter and Wilkinson assessment by substituting spine hypermobility (the ability to touch the palm to the floor while keeping the knees extended) for ankle hyperdorsiflexion and creating a hypermobility score of 0–5, utilizing an average score for the paired joints in the extremities. They described 100 patients with EDS, showing that most obtained a hypermobility score of at least 3, and many demonstrated considerable disability due to joint instability, arthritis, or skin ulceration. In 1973, Beighton et al. (1973) modified the hypermobility score to include each individual joint separately, giving the current maximum score of 9 (Fig. 1, Table 1). Using this scale, a score of ≥4 is indicative of hypermobility (Grahame et al. 2000), although some authors define moderate hypermobility as a score of 3–4 and severe hypermobility as a score of ≥5 (Mikkelsson et al. 1996; Beighton et al. 1998; Juul-Kristensen et al. 2007). Over the years, the Beighton score has gained international acceptance as a screening test for joint hypermobility and has been validated as both reproducible and indicative of pathologic joint instability.

In the Rheumatology literature, the Brighton scale has gained more acceptance (Grahame et al. 2000) especially for the diagnosis of benign joint hypermobility syndrome (BJHS). The diagnosis of BJHS using the Brighton scale includes two major criteria and eight minor criteria. The major criteria are a Beighton score of ≥4 and arthralgias of ≥4 joints for greater than 3 months. The minor criteria include a Beighton score of 1–3, arthralgias of 1–3 joints for greater than 3 months, dislocation/subluxation of 1 joint, soft tissue rheumatism such as epicondylitis or tenosynovitis, marfanoid habitus, abnormal skin findings such as hypermobility or striae, ophthalmologic findings such as ptosis or myopia, and miscellaneous findings of hypermobility such as varicose veins, uterine/rectal prolapse, or hernia.

Injury assessment in individuals with ligamentous laxity proceeds, as in all patients, with a thorough history and physical examination. Patients may present many months after an initial, minor trauma with complaints of pain and disability far beyond what was initially present immediately following the injury. The history of present illness should incorporate all treatment modalities attempted since the dysfunction began, with special care noted as to any previous physiotherapy and which exercises were performed. Additionally, detailed information about previous injuries throughout the body should be obtained. The examiner should have a low index of suspicion and carefully evaluate for hypermobility syndromes, especially in patients where complaints appear out of proportion to physical exam or radiographic findings.

The physical examination should incorporate the Beighton score as a measure of generalized joint laxity as well as a more thorough examination of the affected joint. The affected area should be inspected for edema, ecchymosis, skin tears, or striae and palpated for the area of maximal tenderness. The active and passive ROM of the affected joint should be documented before specialized tests of joint hypermobility are performed. In the shoulder, a sulcus sign (Fig. 2) can be demonstrated with the patient seated or standing, by pulling inferiorly on the adducted shoulder, noting that greater than 2 cm of inferior translation is indicative of shoulder instability. The anterior apprehension sign is elicited with the shoulder abducted to 90°, placing anteriorly directed force combined with external rotation at the shoulder joint, followed by the Relocation test that is done by then placing a posteriorly directed force on the shoulder to assess for relief from shoulder apprehension. Similarly, the posterior apprehension sign is elicited with the shoulder forward flexed to 90° and internally rotated, placing a posteriorly directed force at the shoulder joint. Additionally the Jerk test can be performed in a similar arm position with a rapid posteriorly directed force placed upon the shoulder which can produce painful and palpable posterior subluxation, which is then relieved, often with a palpable clunk, with gradual extension of the arm (Ho et al. 2007). The diagnosis of multidirectional instability occurs when a patient exhibits signs of pathologic instability in more than one anatomical direction, either anteriorly, posteriorly, or inferiorly. Unidirectional or multidirectional instability may occur in the setting of underlying ligamentous laxity, and a careful assessment of both affected and unaffected joints is crucial towards understanding the nature of the patient’s complaints (Cameron et al. 2010).

Examination of the elbow includes an assessment of ROM and hyperextension of the joint. Further instability of the elbow is typically pathologic indicative of laxity or tearing of the medial or lateral ulnar collateral ligament injury, which is assessed by placing valgus and varus stress, respectively, on the joint. Additionally, the lateral pivot-shift test is utilized to assess for posterolateral instability by placing an axial and valgus compressive on the elbow in 40° elbow flexion and full forearm supination (Video 1). The assessment of instability of the elbow is often difficult in a non-sedated patient due to dynamic stability provided by the periarticular musculature, and an exam under anesthesia, including elbow arthrogram, is recommended (Messmer and Ruch 2007).

Assessment of the hand and wrist follows a similar protocol, beginning with inspection to assess for subluxation of the thumb CMC joint or volar/ulnar sag of the wrist, palpation and ROM examination. The assessment of midcarpal instability is performed by placing the wrist in a pronated and ulnarly deviated position and applying volarly directed pressure on the hand, which can generate a palpable clunk (Fig. 3), which is relieved with supination and a dorsally directed force (Video 2). Additionally, assessment of scapholunate instability via the Watson test and luno-triquetral (LT) instability via the LT compression and ballottement tests is recommended to assess for pathologic single ligament wrist instability (Rizzo 2007; van Vugt et al. 1999). Assessment of CMC subluxation and apprehension is performed by placing a dorsally directed force on the trapeziometacarpal joint.

Overall, this assessment should be performed bilaterally to ensure that the examiner can deduce the patient’s state of hypermobility and infer the locations where additional pathologic laxity is present. For patients with an unclear diagnosis or who have failed physiotherapy treatments, further evaluation with advanced imaging is indicated. For patients with soft tissue pain about the wrist, ultrasound has been utilized as an effective technique in aiding diagnosis of subcutaneous injury, whereas bone scintigraphy is best for subtle osseous abnormalities (van Vugt et al. 1999). Additionally, magnetic resonance imaging, especially when supplemented by arthrography, has shown excellent sensitivity and specificity for intra-articular pathology in the shoulder, elbow, and wrist (Lomasney et al. 2013) .

In patients with hypermobility syndromes, the diagnosis is easily missed or delayed, which can lead to worsening pain and dysfunction prior to diagnosis (Grahame and Hakim 2008). While hypermobility by itself does not impart musculoskeletal damage, complaints of pain and dysfunction are common, especially in patients with more severe forms of hypermobility including Marfans or EDS (Rombaut et al. 2010). The key to treatment is to quickly identify a patient with hypermobility and initiate prompt treatment. In most cases, emphasizing musculoskeletal health and core strengthening exercise programs provides the best pathway to recovery following injury (Russek 1999). Patients with fibromyalgia and hypermobility who exercised regularly and had improved general fitness were demonstrated to have improved outcomes compared to those who did not (Ferrell et al. 2004; Goldman 1991). A recent systematic review of patients with benign joint hypermobility syndrome demonstrated that there is limited evidence on therapeutic regimens, but that proprioceptive-based therapeutic exercises and general physiotherapy are beneficial to children with BJHS and musculoskeletal pain (Smith et al. 2014). For patients with shoulder multidirectional instability, focused rotator cuff rehabilitation to impart additional dynamic stability has been advocated as the primary treatment modality (Burkhead and Rockwood 1992; Cameron et al. 2010). Following injury, patients with hypermobility syndromes may have a prolonged course of therapy in order to recover to pre-injury levels of pain and sports participation (Collinge and Simmonds 2009; Simmonds and Keer 2007). Surgical treatment is rarely indicated in patients with joint hypermobility and is limited to cases where additional traumatic injuries or pathologic instability is present despite adequate rehabilitation (Burkhead and Rockwood 1992; Cameron et al. 2010; Neer and Foster 1980).