{"id":29861,"date":"2026-10-30T12:00:00","date_gmt":"2026-10-30T11:00:00","guid":{"rendered":"https:\/\/www.physiotutors.com\/?post_type=research&p=29861"},"modified":"2026-10-17T18:24:42","modified_gmt":"2026-10-17T16:24:42","slug":"beighton-score-acl-reinjury","status":"publish","type":"research","link":"https:\/\/www.physiotutors.com\/research\/beighton-score-acl-reinjury\/","title":{"rendered":"More Hypermobile Joints, Higher Risk: Rethinking the Beighton Score After ACL Reconstruction"},"featured_media":29864,"template":"","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":""},"featured-tag":[],"tracking_tag":[2197,2199],"class_list":["post-29861","research","type-research","status-publish","has-post-thumbnail","hentry","tracking_tag-knee","tracking_tag-sports-rtp"],"acf":{"free_access":"unfree","app_link":"","sections":[{"acf_fc_layout":"page-header-small","background":{"background_image":29864,"background_image_alt_text":"More Hypermobile Joints, Higher Risk: Rethinking the Beighton Score After ACL Reconstruction"},"heading":"More Hypermobile Joints, Higher Risk: Rethinking the Beighton Score After ACL Reconstruction","subheading":"Lindskog et al., Sports Med Open. (2026)","benefits":[{"benefit":"Each additional positive hypermobility test on the Beighton Score was associated with a 10% higher hazard of second ACL injury after return to sport"},{"benefit":"The association was driven mainly by graft rupture (HR 1.15 per point), not by contralateral ACL injury (no significant association)"},{"benefit":"Graft ruptures occurred early (median 7.6 months after RTS), while contralateral injuries occurred much later (median 28 months), suggesting different prevention windows"}]},{"acf_fc_layout":"content","background_color":"none","content_alignment":"left","content_editor":"

Introduction<\/h2>\r\nReinjuries to the reconstructed anterior cruciate ligament (ACL) occur in up to 20% of patients, and it is concerning that nearly one out of five is younger than 25 years. Generalized joint hypermobility (GJH) has long been proposed as a risk factor for a second ACL injury, but how we currently diagnose it is simplistic: a single yes\/no cutoff on the Beighton Score, based on age and sex. That binary approach ignores something clinically obvious: a patient who scores 9\/9 on the Beighton Score<\/a> is probably not at the same risk as one who just barely scrapes past the cutoff with 4 or 5 positive tests.\r\n\r\nThis study asks a more refined question: does the number of positive hypermobility tests, rather than simply crossing a threshold, predict the hazard of a second ACL injury after return to sport (RTS)? If you're counseling patients on re-injury risk after ACL reconstruction, this distinction matters for how precisely you can risk-stratify and communicate with your patients.\r\n\r\n \r\n

Methods<\/h2>\r\nThis registry-based retrospective cohort study used data from Project ACL (Gothenburg, Sweden) to investigate whether evaluating joint hypermobility as a continuous scale (0 to 9) on the Beighton Score<\/a> provides better risk stratification for a second ACL injury (graft rupture or contralateral ACL injury) compared to traditional binary cutoffs for Generalized Joint Hypermobility (GJH)\r\n\r\nPatients aged 15-50 years at the time of their primary ACL reconstruction (using a hamstring tendon or bone-patellar tendon-bone autograft), who had a documented Beighton Score<\/a>, participated in knee-strenuous sports (Tegner \u22656) before injury, and achieved RTS (Tegner \u22656), were eligible.\r\n\r\nThese patients were followed until they either sustained a second ACL injury (graft rupture or contralateral injury) or had \u22651 year follow-up after RTS without one. Multivariable Cox proportional hazard regression (cause-specific HR, accounting for competing risks) estimated the hazard of second ACL injury based on the Beighton Score (treated as a continuous count of positive tests, 0-9), adjusted for age, return to pre-injury activity level, graft choice, knee hyperextension, and sex.\r\n\r\nTo learn how to evaluate the Beighton Score in practice, we refer you to our app<\/a>. An Injury Allowance Point was used when assessing a knee that exhibits restricted range of motion or surgical stiffness. The authors then assigned the result of the uninjured (contralateral) side to the operated side, to prevent underestimating the patient's baseline constitutional hypermobility.\r\n\r\n \r\n

Results<\/h2>\r\nA total of 935 patients were included; their mean age was 23.7 \u00b1 7.8 years, and 51.4% were female. The median Beighton Score was 2 (IQR 4). Median follow-up after RTS was 54.4 months. The overall cumulative incidence of a second ACL injury was 13.1% (7.4% graft rupture, 5.7% contralateral injury).<\/span>\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\nThe median follow-up time from the RTS to the endpoint was 54.4 months, and this was significantly different between patients with different total Beighton Scores. Those scoring 9\/9 had the shortest follow-up time after RTS until a second injury occurred: 24.7 months.\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\nFor the primary outcome, each additional positive hypermobility test was associated with a significantly increased hazard of second ACL injury: adjusted HR 1.10 (95% CI 1.003-1.22, p=0.044).\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\nThe secondary outcome, for graft rupture specifically, had an adjusted HR of 1.15 (95% CI 1.01-1.30, p=0.031). For contralateral ACL injury, there was no significant association (adjusted HR 1.04, 95% CI 0.89-1.21, p=0.598).\r\n\r\n\"\"\r\n\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/em><\/a>\r\n\r\nFrom: Lindskog et al., Sports Med Open. (2026)\r\n\r\nBecause the effect is a hazard ratio per point, it compounds: the authors calculated that patients with 1, 2, or 3 positive tests had an estimated 10%, 21%, or 33% higher hazard of second ACL injury, respectively, compared to patients scoring 0. Timing also differed: graft ruptures occurred early (median 7.6 months post-RTS) while contralateral injuries occurred much later (median 28 months post-RTS).\r\n\r\n \r\n

Questions and thoughts<\/h2>\r\nThis study nudges us away from a simple \u201cyes\/no\"-rating of a continuous measure (Beighton Score), toward thinking of joint hypermobility as a spectrum, which actually fits better with how most other risk factors in rehab work. Think of strength asymmetry, psychological readiness, or even age, which we rarely treat as hard cutoffs either. A patient with 2 positive Beighton tests is not in the same risk category as one with 8, even if neither one meets the formal generalized joint hypermobility threshold, or both do.\r\n\r\nClinically, this means the Beighton Score shouldn't just be scored as \"positive\" or \"negative\" against a lookup table. The purpose is to count the actual number of positive tests and use that as a continuous piece of information in your risk conversation and RTS planning.\r\n\r\nThe striking timing difference between graft rupture (early, median 7.6 months) and contralateral injury (late, median 28 months) also deserves attention. It suggests that graft rupture and contralateral injury are probably driven by partly different mechanisms, possibly graft maturation\/biomechanical factors early on versus behavioral\/exposure factors later. This also explains why the overall \"second ACL injury\" association was mostly carried by graft rupture: hypermobility may matter more for the structural integrity of the graft itself than for whatever drives a patient to injure the other knee years later.\r\n\r\n \r\n

How should rehabilitation timelines be adjusted for athletes with high hypermobility scores?<\/h3>\r\nBecause graft ruptures occurred early after RTS (median 7.6 months), hypermobile athletes may benefit from extended tissue-remodeling phases and delayed RTS clearance (e.g., 12 to 15+ months post-op) combined with objective neuromuscular criteria, rather than time-based progression alone.\r\n\r\n \r\n

How can we educate patients on their increased hazard ratio without causing fear of movement or sports participation?<\/h3>\r\nCommunicating a continuous risk profile (e.g., explaining that joint laxity requires greater active muscular control) allows clinicians to frame hypermobility not as an insurmountable pathology, but as a manageable physical trait requiring targeted neuromuscular conditioning.\r\n\r\n \r\n

What specific training modalities best offset passive tissue laxity during high-impact, cutting maneuvers?<\/h3>\r\nSince hypermobile joints lack passive structural restraint, exercise programs should emphasize heavy slow resistance, eccentric strength, rate of force development (RFD), trunk\/hip motor control, and stiff landing mechanics to enhance dynamic joint stability.\r\n\r\n \r\n

Talk nerdy to me<\/h2>\r\nFrom an initial registry cohort of 4,933 patients, only 935 (19.0%) met all inclusion criteria. A significant number were excluded due to missing Beighton Scores (n=713) or missing RTS documentation (n=700). Non-random missingness or differential follow-up durations across hypermobility tiers could introduce selection or attrition bias, potentially affecting hazard ratio calculations at the upper extreme of the hypermobility spectrum.\r\n\r\nFurthermore, the registry data did not track concomitant structural injuries (e.g., lateral meniscus tears, medial collateral ligament injury) or secondary surgical stabilizations such as Lateral Extra-Articular Tenodesis (LET) or Anterolateral Ligament (ALL) reconstruction. Concomitant LET or ALL procedures can possibly reduce graft failure rates<\/a> in hypermobile patients. Unmeasured variation in surgical techniques across the registry could have also confounded the relationship between hypermobility and graft rupture.\r\n\r\nAlthough the study evaluates the aggregate Beighton Score as a continuous variable (0\u20139), each individual component test remains a binary cutoff (e.g., knee hyperextension >10\u00b0 vs. <10\u00b0). Binary scoring for each joint does not account for continuous variations in joint angle (e.g., 11\u00b0 vs. 25\u00b0 of knee hyperextension) or multi-directional joint laxity not captured by the 9 standard Beighton maneuvers.\r\n\r\nA few methodological points are worth flagging. First, the adjusted HR for the primary outcome had a confidence interval that just barely excludes 1 (1.003-1.22). This is a statistically significant finding, but not a robust effect size, as the lower bound tells you this finding is fragile. Don't walk away thinking hypermobility is a strong, standalone predictor; it's a modest, incremental one.\r\n\r\nSecond, the HR is multiplicative per point, not additive. The \"10%, 21%, 33%\" figures for 1, 2, 3 positive tests reported by the authors are the compounded (exponential) effect of a constant per-unit HR, not a linear accumulation. This is an elegant way to communicate it, but also means it can sound more dramatic than it is: going from 0 to 3 positive tests is still \"only\" a one-third relative increase in hazard, applied to a fairly low absolute baseline risk.\r\n\r\nThird, only 117 patients (12.5%) scored \u22656 on the Beighton Score, meaning the higher end of the hypermobility spectrum is thinly represented, but that is exactly where you'd want the most precision if you're trying to counsel your most hypermobile patients. The model's discrimination was also only \"possibly helpful\" (Harrell's C = 0.621 for the primary outcome, 0.660 for graft rupture, and a poor 0.599 for contralateral injury), meaning that the Beighton Score plus the adjustment variables combined still doesn't discriminate who will versus won't sustain a second ACL injury particularly well on an individual level. This is a population-level signal, not an individual-level crystal ball.\r\n\r\nOther limitations: individual joint angles within each Beighton test weren't captured (only positive\/negative per test), and the exact sport exposure\/intensity wasn't accounted for (only Tegner activity level).\r\n\r\n \r\n

Take-home messages<\/h2>\r\nJoint flexibility exists along a continuum. For athletes returning to knee-strenuous sports following ACL reconstruction, every additional hypermobile joint on the 9-point Beighton Score raises the risk of tearing the surgical graft by 15%. When assessing second ACL injury risk after RTS, don't just dichotomize the Beighton Score into \"hypermobile\" or \"not\".\r\n\r\nCount and communicate the actual number of positive tests, as each additional positive test independently raises the hazard of a second ACL injury (particularly graft rupture).\r\n\r\nPair this with a time-based prevention strategy: focus on graft protection and loading progression in the first year post-RTS when graft rupture risk peaks, but keep contralateral injury prevention efforts (movement quality, neuromuscular control) going well beyond year one, since that risk emerges later and isn't predicted by hypermobility.\r\n\r\n \r\n

Reference<\/h2>\r\nLindskog J, Zsidai B, Sundberg A, H\u00f6gberg J, Hamrin Senorski R, Liaghat B, Samuelsson K, Thome\u00e9 R, Piussi R, Hamrin Senorski E. Increased Hazard Ratio of a Second ACL Injury After Return to Sport for Each Positive Hypermobility Test on the Beighton Score: A Registry Study. Sports Med Open. 2026 Jun 23;12(1):79. doi: 10.1186\/s40798-026-01054-5. PMID: 42334734; PMCID: PMC13291372.<\/a>"},{"acf_fc_layout":"author","author":{"":null,"image":25230,"image_alt_text":"","name":"Ellen Vandyck","function_or_description":"Research Manager"}}]},"yoast_head":"\nBeighton Score and ACL Reinjury Risk<\/title>\n<meta name=\"description\" content=\"Each positive Beighton Score test raises second ACL injury hazard after RTS. 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