You may have never connected your flexible joints to your gut problems. Most gastroenterologists do not ask about joint hypermobility during a SIBO workup, and most rheumatologists do not ask about bloating and diarrhea. But the connection between connective tissue laxity and small intestinal bacterial overgrowth is well established in the research literature, and it explains why a significant subset of SIBO patients relapse repeatedly despite doing everything right. Screening for hypermobility is simple, free, and can be done at home. If the results are positive, it opens a diagnostic and treatment pathway that can make a meaningful difference in long-term SIBO management.
The Beighton score explained
The Beighton score is a 9-point scoring system that assesses joint hypermobility at five sites. It was originally developed by Peter Beighton in 1973 and remains the internationally accepted screening tool for generalized joint hypermobility. Each maneuver is scored 0 (not hypermobile) or 1 (hypermobile), with bilateral tests scored separately for left and right sides.
- Passive dorsiflexion of the fifth finger beyond 90 degrees (1 point per side, 2 points total). With your hand flat on a table, pull the little finger back. If it bends past 90 degrees, score 1 for that side.
- Passive apposition of the thumb to the forearm (1 point per side, 2 points total). Bend your wrist and push your thumb toward the front of your forearm. If the thumb touches the forearm, score 1.
- Hyperextension of the elbow beyond 10 degrees (1 point per side, 2 points total). Straighten your arm fully. If the elbow bends backward past straight by more than 10 degrees, score 1.
- Hyperextension of the knee beyond 10 degrees (1 point per side, 2 points total). Stand with legs straight. If your knee bows backward beyond straight by more than 10 degrees, score 1.
- Forward flexion of the trunk with knees straight so that the palms rest flat on the floor (1 point). Stand with feet together, knees locked straight, and bend forward. If your palms can rest flat on the floor, score 1.
Interpreting your Beighton score
The threshold for generalized joint hypermobility varies by age and sex, reflecting the normal decrease in flexibility that occurs with aging. For adults under 50, a score of 5 or more out of 9 suggests generalized hypermobility. For adults over 50, a score of 4 or more is used because joint flexibility naturally decreases with age. For prepubertal children and adolescents, a score of 6 or more is the threshold, as children are naturally more flexible. It is important to understand that the Beighton score screens for generalized hypermobility, not for EDS specifically. Many people are hypermobile without having a connective tissue disorder. The Beighton score is the first step in a multi-step diagnostic process.
âšī¸Historical hypermobility counts. If you were hypermobile when younger (could do splits, had frequent sprains, were called double-jointed) but have stiffened with age or injury, mention this to your evaluating clinician. The 2017 hEDS criteria allow for historical hypermobility in patients whose Beighton score no longer meets threshold.
Beyond the Beighton score: the 2017 hEDS criteria
A positive Beighton score is necessary but not sufficient for an hEDS diagnosis. The 2017 international diagnostic criteria for hypermobile EDS require three conditions to be met simultaneously. Criterion 1 is generalized joint hypermobility (positive Beighton score or historical evidence). Criterion 2 requires two or more of the following features: systemic manifestations of connective tissue disorder (scored checklist including skin hyperextensibility, piezogenic papules, dental crowding, arachnodactyly, mild mitral valve prolapse, or others), positive family history of hEDS in a first-degree relative, or musculoskeletal complications (chronic pain, recurrent dislocations, atraumatic joint instability). Criterion 3 requires exclusion of other connective tissue disorders, autoimmune conditions, and alternative diagnoses. The full criteria are available from the Ehlers-Danlos Society and should be evaluated by a knowledgeable clinician.
Hypermobility spectrum disorder: when you are hypermobile but do not meet hEDS criteria
Patients who have symptomatic hypermobility but do not meet the full 2017 hEDS criteria are classified as having hypermobility spectrum disorder (HSD). HSD is not a lesser diagnosis. It acknowledges that hypermobility can cause significant symptoms, including chronic pain, fatigue, and GI dysfunction, even without meeting every hEDS criterion. Whether HSD carries the same degree of SIBO risk as hEDS is not yet established, but clinical experience suggests that any degree of symptomatic hypermobility associated with gut dysmotility is relevant to SIBO management. The distinction between HSD and hEDS matters most for genetic counseling and screening for specific complications (such as vascular complications in other EDS subtypes) rather than for SIBO treatment decisions.
Genetic testing for EDS
Genetic testing can confirm the diagnosis of most EDS subtypes because they have identified causative mutations. Classical EDS is caused by mutations in COL5A1 or COL5A2. Vascular EDS is caused by mutations in COL3A1. Kyphoscoliotic EDS involves PLOD1 or FKBP14. Other rare subtypes have their own identified genes. However, the genetic basis of hEDS (the most common subtype and the one most associated with SIBO) remains unknown. No genetic test can confirm or rule out hEDS. This means that a negative genetic panel does not exclude hEDS if the clinical criteria are met. Genetic testing is most useful when vascular EDS is suspected (because of its serious arterial complications) or when the clinical picture is atypical and other subtypes need to be evaluated. Your evaluating geneticist will determine whether genetic testing is indicated based on your clinical presentation.
POTS screening for SIBO patients with hypermobility
Postural orthostatic tachycardia syndrome (POTS) is the missing link in many EDS patients' SIBO management. POTS occurs in an estimated 50-80% of hEDS patients and directly impairs gut motility through autonomic dysfunction. Screening for POTS can be done with a simple standing test. After lying down for 5 minutes, stand up and measure your heart rate at 1 minute and at 10 minutes. An increase of 30 beats per minute or more (or a standing heart rate above 120 bpm) within 10 minutes of standing, without a significant drop in blood pressure, suggests POTS. Formal diagnosis requires a tilt table test, but the standing test is a useful screen. Symptoms of POTS include lightheadedness or dizziness on standing, rapid heartbeat with position changes, fatigue, brain fog, exercise intolerance, and sometimes nausea or abdominal pain that worsens with standing.
Managing EDS-associated SIBO
When hypermobility is identified as a root cause of SIBO, the management plan expands beyond standard eradication and prokinetics. The approach integrates SIBO-specific treatment (antibiotics or herbal antimicrobials for active overgrowth), long-term prokinetic therapy (often needed indefinitely because the connective tissue defect is permanent), POTS management (increased fluid and salt intake, compression garments, and sometimes medications like fludrocortisone, midodrine, or ivabradine), physical therapy (specifically designed for hypermobile patients to stabilize joints and improve overall function without exacerbating laxity), dietary modifications (smaller, more frequent meals to accommodate slowed transit; FODMAP reduction during flares), and regular monitoring for nutritional deficiencies. The multidisciplinary nature of this approach requires coordination between gastroenterology, cardiology or autonomic medicine (for POTS), genetics (for EDS evaluation), and physical therapy.
- Treat active SIBO with standard antibiotic or herbal protocols.
- Start prokinetic therapy and plan for long-term use.
- Screen for and treat POTS if present (fluids, salt, compression, medications as needed).
- Seek EDS-knowledgeable physical therapy for joint stabilization.
- Eat smaller, more frequent meals. Consider FODMAP reduction during active flares.
- Monitor nutritional status regularly (B12, iron, fat-soluble vitamins).
- Coordinate care across gastroenterology, genetics, cardiology/autonomic medicine, and physical therapy.
Frequently Asked Questions
Can I use the Beighton score to diagnose myself with EDS?
No. The Beighton score screens for generalized hypermobility, which is one part of the hEDS diagnostic criteria. Many hypermobile people do not have EDS. A formal diagnosis requires evaluation of systemic features, family history, and exclusion of other conditions by a qualified clinician (ideally a geneticist or knowledgeable rheumatologist).
I was flexible as a child but not anymore. Does that still count?
Yes. The 2017 hEDS criteria recognize historical hypermobility. Joint flexibility decreases with age, injury, and deconditioning. If you had significant hypermobility earlier in life (doing splits easily, frequent joint subluxations, being called double-jointed), that history is clinically relevant even if your current Beighton score is lower.
What kind of doctor diagnoses EDS?
Medical geneticists are the primary specialists for EDS diagnosis. Some rheumatologists have expertise in connective tissue disorders. Finding a clinician specifically experienced with EDS is important because many physicians are unfamiliar with the condition. The Ehlers-Danlos Society maintains a directory of knowledgeable providers.
How common is hypermobility in SIBO patients?
Formal prevalence studies are lacking, but clinical reports consistently describe hypermobility as overrepresented in SIBO populations compared to the general population. Several SIBO specialists have noted that screening for hypermobility in their recurrent SIBO patients reveals previously undiagnosed EDS or HSD at rates well above the expected population prevalence.
â ī¸This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition.