Hospital del Mar criteria: Scoring, interpretation, and clinical use

Key takeaways

The Hospital del Mar criteria scores 10 hypermobility items at one point each, for a maximum of 10. Bulbena and colleagues developed it in Barcelona.

The published cut-off is sex-specific. Men meet it at 4 or more positive items, and women at 5 or more.

Unlike the Beighton score, it includes no trunk-flexion maneuver and covers more peripheral joints. That is why it reports higher prevalence.

Practice management software like Pabau stores each score as a structured field per visit, so trends and referral thresholds stay visible at follow-up.

Clinicians managing hypermobility-related conditions face a persistent documentation problem. The Beighton score has dominated joint hypermobility screening for decades. Its 9-point scale misses several peripheral joints that frequently cause symptoms.

The Hospital del Mar criteria takes a wider view. It scores 10 items across the hand, the limbs, and the skin, one point each. This guide covers how the tool works, how to score it, and how to read the result. It also sets the two instruments side by side, so you can see which one fits the patient in front of you.

What is the Hospital del Mar criteria?

The Hospital del Mar criteria is a structured clinical assessment tool for generalized joint hypermobility (GJH). Bulbena and colleagues developed it at Hospital del Mar in Barcelona as an alternative to the Beighton score. The aim was to capture hypermobility across a wider range of peripheral joints.

You will also see it cited as the Bulbena score, or simply the Bulbena criteria, after its lead author. All three names describe the same assessment.

The tool is used primarily by physical therapists, rheumatologists, and other musculoskeletal clinicians. It is not a standalone diagnostic instrument for any condition. That includes hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD).

Nine of the 10 items are joint maneuvers, spanning the thumb, fifth finger, elbow, shoulder, hip, patella, knee, ankle and foot. The tenth records a skin sign, bruising after minimal trauma. There is no trunk-flexion maneuver, which is the clearest structural difference from the Beighton score.

You will meet the tool in two places. The first is routine musculoskeletal assessment in a physical therapy practice. The second is a rheumatology workup where the Beighton score came back low despite obvious peripheral laxity.

How the Hospital del Mar criteria works: The 10 items assessed

Each item tests one joint or, in the case of bruising, one clinical sign. A positive finding scores one point and a negative finding scores nothing. The table below sets out all 10 items, the maneuver used, and the threshold that counts as positive.

Each joint maneuver is tested passively on both sides. An item still contributes only one point, whether the finding is one-sided or bilateral. That is what keeps the maximum at 10 rather than 20, and it is the detail clinicians most often get wrong.

Assessment requires physical examination by a trained clinician, so it cannot be self-administered. The thumb and fifth-finger maneuvers are the two patients already know. What people call the double-jointed fingers test is exactly this pair, and patients often demonstrate it before you ask.

Clinicians using digital assessment forms can standardize how hypermobility findings are captured and linked to each patient record. That removes most of the incomplete documentation you get across a busy caseload.

How to score the Hospital del Mar criteria

Scoring is straightforward. Each positive finding adds one point, and the maximum possible score is 10. A higher score indicates greater generalized hypermobility.

Interpretation is where the tool differs most from the Beighton score. Bulbena and colleagues published a sex-specific threshold. Men reach it at 4 or more positive items out of 10, and women at 5 or more.

Women tend to score higher than men on hypermobility testing, which is why the female threshold sits one point above the male one. The consequence is easy to miss in a busy clinic. A man scoring 4 out of 10 meets the threshold, while a woman with the identical score does not.

So a raw total on its own is not a result. Record the score, the sex-specific threshold you applied, and the version of the tool you used. Anything less leaves the next clinician guessing.

Interpreting your results: What the score means

Interpretation starts with the published cut-off, then widens to the clinical context. The table below sets out how each band is usually read, and what it tends to prompt next.

A positive screen does not confer a diagnosis of hEDS or hypermobility spectrum disorder. Both need broader diagnostic criteria than any single assessment score can supply.

The 2017 hEDS criteria from the Ehlers-Danlos Society ask for a good deal more. They require evidence of systemic connective tissue involvement, musculoskeletal complications, and family history alongside the hypermobility finding.

Spinal involvement is a separate question this tool does not answer. Where a patient’s symptoms point at the lumbar spine, an inflammatory cause such as M45.6 needs ruling in or out on its own evidence.

Hospital del Mar criteria vs Beighton score: Key differences

Three differences separate the two tools. The Hospital del Mar criteria scores 10 peripheral items and includes no trunk-flexion maneuver. The Beighton score scores 9 points across five maneuvers, one of which is trunk forward flexion. And their thresholds work differently, because only one of them is sex-specific.

Naming causes confusion as well. The Beighton score turns up in the literature and in patient conversations as Beightons score, and as the Beighton hypermobility scale. The Hospital del Mar test carries the Bulbena name just as often as the hospital name.

Hips are the clearest example of what the two tools see differently. The Beighton test has no hip item at all, so a patient with marked hip laxity can still score low. The Hospital del Mar criteria scores hip abduction to 85 degrees or more. That single item is often why the same patient’s result moves.

The table below sets the two instruments side by side on the axes that decide which one you reach for. That includes origin, alternative names, thresholds, and typical clinical use.

The size of that prevalence difference is worth knowing before you switch tools. A study of school children applied both instruments to the same cohort. The Beighton score flagged 12 percent as hypermobile, while the Hospital del Mar criteria flagged 34 percent.

That is close to a threefold difference in the same children. It reflects broader item coverage rather than a sharper ability to detect hypermobility that actually matters clinically. Read a high Hospital del Mar score in that light.

Validity, reliability, and the research evidence

The Hospital del Mar criteria has a smaller validation evidence base than the Beighton score. Factor that in before you build it into a standard assessment protocol.

Both tools sit inside a wider workup for Ehlers-Danlos syndrome (EDS). The 2017 hEDS framework uses the Beighton score as its first criterion, which makes Beighton the standard opening move. Rheumatology referrals therefore tend to ask for a Beighton score by name.

Part of the reason is the Beighton cut-off of 4/9, which gives two clinicians a figure they can compare directly. No score, from either tool, confirms a diagnosis alone.

• Inter-rater reliability: studies suggest acceptable agreement when trained clinicians perform the assessment. Formal reliability data across large studies remains limited.
• Sensitivity: broader item coverage identifies more people as hypermobile. That gives the tool higher sensitivity for GJH than the Beighton score in some populations.
• Specificity: fewer large-scale specificity studies exist than for the Beighton score. Do not use it as a standalone rule-out tool.
• Prevalence comparisons: research consistently returns higher estimates than Beighton in the same cohorts. That may reflect genuine capture of broader involvement, or a looser effective threshold.

Single-maneuver tests behave the same way, which is why they are graded on the same axes. The full can test is a useful comparison, since its value also rests on sensitivity and examiner technique rather than the finding alone.

The Ottawa ankle rules show the pattern in a different joint, where a short rule set decides who needs imaging. The Physiopedia entry on the Hospital del Mar criteria is the quickest reference for the maneuvers themselves.

Limitations of the Hospital del Mar criteria

Each limitation below changes either what the score can be used for, or how much weight it should carry in a decision.

• Sex-specific thresholds: because the cut-off is 4 for men and 5 for women, raw totals cannot be compared across sexes without applying the right threshold.
• No trunk-flexion item: where spinal mobility is the primary concern, the Beighton score captures that component and this tool does not.
• Limited validation literature: it has fewer large-scale psychometric studies than the Beighton score across diverse clinical populations.
• Training dependency: accurate administration needs hands-on training. Measurement error between clinicians of different experience affects reliability in practice.
• Not diagnostic: the criteria screens for generalized joint hypermobility. It does not diagnose hEDS, HSD, or any specific condition on its own.

Complex presentations need more than one data point. An association between joint hypermobility and ADHD has been proposed in emerging research, alongside autism, and that evidence remains preliminary.

No hypermobility instrument screens for either condition. If a patient raises the connection, document the joint findings and refer separately. A dedicated tool such as an impulsivity test fits that pathway better.

When to use the Hospital del Mar criteria in clinical practice

Reach for the Hospital del Mar criteria when the clinical question concerns peripheral joint hypermobility. It earns its extra minutes when the Beighton score’s narrower coverage would understate how widespread the laxity is.

• Patients with mainly peripheral symptoms in the fingers, ankles, feet, and hips. The Beighton score’s five maneuvers can return a low total despite widespread laxity.
• Research and prevalence work where a higher-sensitivity instrument is needed to capture population-level rates.
• HSD and hEDS workup where a broader peripheral assessment supports the picture, used alongside the Ehlers-Danlos Society’s diagnostic guidelines.
• Structured assessment protocols where all 10 items can realistically be completed inside the consultation time available.

Athletes are a common reason to choose it, since laxity in the shoulders, hips, and ankles drives their presentation. Practices running sports medicine software tend to score these joints as a matter of routine.

Return-to-running protocols show how a structured score feeds a rehab plan instead of sitting in the notes. For patient-facing explanations of Beighton ranges, Medical News Today is a useful plain-language companion.

How Pabau supports hypermobility assessments in clinical practice?

Written into a free-text note, a score of 5 out of 10 is just a number inside a sentence. Three visits later, nobody can tell whether it was an improvement, a decline, or a second clinician reading the same joints differently.

Practice management software like Pabau handles this differently. You build the Hospital del Mar criteria once as a digital assessment form. Each item gets its own structured field, plus a field for the total and one for the threshold applied.

Each completed form attaches to the patient’s clinical record. Every visit then adds a dated score rather than another paragraph of prose that someone has to read to the end.

Because those totals are structured fields, measurements tracking can trend them across visits. For a patient with chronic hypermobility, isolated numbers become a line you can show them in the room.

That also makes your referral threshold usable. A result that crosses it is visible at the next appointment, not buried in a note from six months ago.

Structured client records link the assessment to appointment history, treatment notes, and follow-up scheduling. The whole clinical team then reads the same information without a manual filing system. That matters most in hypermobility care, where up-to-date records are the only way to see change over time.

Physical therapy practice management software keeps assessment documentation, scheduling, and patient communication in one system instead of three. Each result then stays attached to the patient context it belongs to.

Score hypermobility once, find it every time

Pabau lets physical therapists and rheumatologists build the 10 items as a structured form. Each total attaches to the patient record, and follow-up care is scheduled in the same place. See how it works for your practice.

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Conclusion

The Hospital del Mar criteria earns its place when the peripheral joints carry the symptoms. Its 10 items reach the hip, patella, and forefoot, which the Beighton score’s five maneuvers never touch. The trade is a longer exam and a thinner validation literature.

For routine screening, the Beighton score remains better validated and more widely referenced. Use the Hospital del Mar criteria when the presentation looks broader than Beighton captures. Then write down the threshold you scored against, because the male and female cut-offs are not the same.

Whichever tool you choose, a score only changes care if the next clinician can find it and compare it. Book a demo to see how Pabau keeps hypermobility scores and follow-up care in one patient record.

Continue your research

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Want guidance on interpreting another scored assessment? Beery VMI scoring and interpretation shows how structured scoring frameworks work across different instruments.

Starting or scaling a physical therapy practice? Opening a physiotherapy clinic walks through the operational and compliance requirements for private practice.

Need a structured approach to clinical documentation? Physiotherapy clinic management software covers how one platform can hold assessment, scheduling, and records together.

Measuring outcomes rather than one-off findings? Patient satisfaction survey software explains how to collect structured feedback alongside your clinical scores.

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