Strength Isometric Test: Paper-Grip Test – 2–5 Toes

The Paper-Grip Test – 2–5 Toes [Muscle Meter] measures how much force is required to pull a card or paper strip from underneath the lesser toes while the client attempts to grip it. It is commonly used to assess toe-grip force through toes 2–5 in a practical foot-strength setup. This can provide useful context for balance, walking, running, foot control, footwear tolerance, lower-limb loading and progress tracking.

The Muscle Meter is used to quantify the pulling force required to remove the paper or card. When used on its own, the Muscle Meter primarily measures peak force, which is the highest force value recorded during the pull. When used with Measurz, Muscle Meter data can be recorded and analysed with broader force-time metrics, including peak force, impulse, torque, rate of force development, time to peak and fatigue index.

For routine 2–5 toe paper-grip testing, peak force is usually the main metric. Force as a percentage of body weight may be useful if directly calculated from the client’s test force and body weight, especially for baseline comparison, side-to-side comparison and retesting. Torque is usually not required unless a specific lever arm and biomechanical model are being used. Rate of force development and time to peak are usually less central because the test focuses on the force required to remove the paper rather than rapid toe force production. Impulse and fatigue index are only relevant if repeated or sustained toe-grip trials are intentionally included.

The result can support assessment reasoning and progress tracking, but it does not diagnose foot pain, toe deformity, neuropathy, falls risk, plantar fasciopathy, balance impairment, sport readiness or work capacity on its own.

What Is the Paper-Grip Test – 2–5 Toes [Muscle Meter]?

The Paper-Grip Test is a practical toe-grip assessment where a paper strip or card is placed under the toes and the client attempts to hold it down while the professional pulls it away.

The 2–5 toes version focuses on the lesser toes rather than the hallux. The Muscle Meter can be used to quantify the pulling force needed to remove the paper from under toes 2–5.

This test is useful because lesser-toe grip can contribute to foot contact, toe purchase, balance strategies and walking or running tasks. However, the result is strongly influenced by setup and toe position.

Consistent setup matters because paper material, paper width, toe contact area, toe shape, skin condition, surface friction, body position, pulling direction, pulling speed and client effort can all affect the result. This test measures toe-grip force in a specific setup. It does not fully measure balance, gait, foot posture, neurological status, falls risk or sport performance on its own.

Step-by-Step Protocol / Practice

1. Prepare the client

Explain that the test measures how strongly they can grip a paper or card with toes 2–5 while it is pulled away.

Record baseline symptoms, toe pain, forefoot pain, arch discomfort, numbness, altered sensation, fatigue, recent activity, footwear and confidence with the test.

Use one gentle practice trial so the client understands the task.

2. Set the client position

Use a repeatable position.

A common setup is seated, barefoot, with the foot flat on the floor and the knee flexed.

Record:

• seated or standing position
• side tested
• barefoot or footwear condition
• knee angle
• foot position
• heel position
• lesser-toe position
• surface type
• whether body weight is loaded through the foot
• paper or card type

3. Set up the Muscle Meter

Attach or connect the paper/card to the Muscle Meter so the device records the pulling force required to remove it from under toes 2–5.

Record the paper width, paper material, attachment method and whether the pull is straight, angled, horizontal or slightly upward.

4. Place the paper or card

Place the paper or card under the plantar surface of toes 2–5.

Try to standardise how much paper sits under the toes and whether the hallux is included or excluded. In this version, the hallux should usually be kept clear of the paper unless the protocol states otherwise.

5. Stabilise the position

Ask the client to keep the foot still and avoid lifting the heel, gripping with the hallux, shifting weight, gripping the floor with the whole foot or pressing down through the ankle.

The aim is controlled lesser-toe grip.

6. Give clear instructions

Use consistent instructions such as:

“Grip the paper with your smaller toes and try not to let me pull it away.”

“Keep your big toe relaxed if possible.”

“Keep your foot still.”

“Do not lift your heel.”

“Keep breathing.”

“Tell me if you feel pain, cramping, tingling or anything unusual.”

7. Record trials

Use one practice trial, then record 2–3 measured trials.

Pull the paper consistently until it slips free or the endpoint is reached.

Rest briefly between trials if toe cramping or fatigue occurs.

Record whether the final score uses the best trial or average of recorded trials.

8. Identify invalid trials

Repeat or mark a trial as invalid if:

• the paper placement changes
• the heel lifts
• the foot slides
• the hallux assists when it should be excluded
• the paper tears
• the Muscle Meter attachment slips
• the pulling direction changes
• pain or cramping limits effort
• the pull is performed too quickly or inconsistently
• the client uses whole-foot bracing rather than lesser-toe grip

9. Record symptoms

Record toe pain, forefoot pain, arch discomfort, cramping, numbness, tingling, confidence, apprehension and symptom response after testing.

For retesting, match the same position, paper type, device setup, paper placement, pull direction, scoring method and symptom recording.

Why It Is Used

The Paper-Grip Test – 2–5 Toes [Muscle Meter] is used to quantify lesser-toe gripping force in a practical setup.

It may be useful for:

• baseline lesser-toe grip assessment
• side-to-side comparison
• monitoring change over time
• tracking foot strength after reduced loading
• supporting balance and walking assessment
• providing context for running, jumping and foot control
• comparing lesser-toe grip with hallux grip
• reviewing foot function in older adults
• client education

The test should support assessment reasoning. It should not be used as a stand-alone diagnostic or clearance measure.

What It Measures

The test primarily measures the pulling force toes 2–5 can resist in the chosen paper-grip setup.

It may provide useful information about:

• lesser-toe grip force
• side-to-side difference
• confidence gripping with toes 2–5
• cramping or symptom response
• change in force over time
• relationship between lesser-toe function and related foot tasks

It does not directly measure:

• isolated intrinsic foot muscle strength
• nerve conduction
• cause of foot pain
• falls risk
• balance
• gait quality
• foot posture
• plantar fascia status
• sport readiness
• work readiness

Understanding the Result, Reference Values and What to Look For

What a higher or lower result may suggest

A higher score may suggest greater lesser-toe gripping force in that specific paper-grip setup. A lower score may suggest reduced force, but the reason should be interpreted carefully.

Lower force may be influenced by pain, altered sensation, cramping, poor familiarisation, toe deformity, reduced toe contact, slippery skin, fatigue, apprehension, inconsistent paper placement or reduced confidence.

One result should not be interpreted in isolation. Interpretation is strongest when the same setup is repeated over time and reviewed alongside symptoms, balance, gait, foot posture, hallux grip, calf capacity, ankle mobility and functional goals.

What can influence the result

Important influences include:

• paper type
• paper width
• paper placement
• whether the hallux is excluded
• toe contact area
• skin condition
• toe shape
• foot position
• body position
• surface friction
• pulling direction
• pulling speed
• pain
• cramping
• altered sensation
• client confidence

Normative, reference and comparative values

Published Muscle Meter-specific universal norms for the exact 2–5 toes paper-grip setup may be limited.

Most enhanced paper-grip research has focused on hallux grip force, so lesser-toe results should be interpreted with extra caution unless the reference method matches closely.

For routine Measurz use, the most useful comparisons are:

• the client’s own baseline
• right versus left comparison
• change across retests
• comparison with 1st-toe paper-grip force
• pain or cramping response
• confidence during testing
• relationship to balance, walking, running or foot symptoms
• force as a percentage of body weight if directly calculated

A side-to-side difference is worth reviewing when it matches symptoms, previous injury, balance findings, gait observations or functional concerns. It should not be used as a strict pass/fail rule.

Reference values provide context, not diagnostic or clearance cut-offs.

Practical interpretation priorities

Use this order:

• compare with the client’s own baseline
• compare right and left sides when relevant
• compare with hallux paper-grip findings if available
• consider symptoms during and after testing
• consider toe contact and paper placement consistency
• review whether compensations were present
• compare with related foot, ankle, balance and gait tests
• relate the result to walking, running, sport, work or daily-life demands
• retest under the same conditions to monitor change
• do not use reference values as pass/fail criteria

What to Look at for Each Relevant Muscle Meter Metric

Peak force

Use for the maximum force resisted before the paper/card is removed.

Look for consistent setup, side-to-side difference, change from baseline, comparison with hallux grip, symptom response and whether the paper placement and pull direction were consistent.

Force as percentage of body weight

Use only when calculated directly from test force and body weight.

This may provide useful context, especially because body mass influences foot loading, but it should not be treated as a universal target unless comparison data use the same method.

Torque

Torque is usually not needed for routine paper-grip testing.

Use only if a specific lever arm and biomechanical interpretation are intentionally included.

Rate of force development

RFD is usually not central because the test measures grip force resisting paper removal rather than rapid toe force production.

Use only if the protocol is designed for rapid toe gripping.

Time to peak

Time to peak is usually not central for routine use.

It may be useful only if the same controlled pull pattern is used and force-time behaviour is being reviewed.

Impulse

Use only if a sustained gripping window is intentionally tested.

Fatigue index

Use only if repeated or sustained toe-grip trials are part of the protocol.

Assessing and Providing Context for Different Client Populations

Youth clients

Consider attention, coordination, foot size, task understanding and ability to isolate the lesser toes. Practice trials are useful.

Adults and general fitness clients

Use the test for baseline foot-strength context, progress tracking and comparison with walking, running or gym goals.

Older adults

Consider balance, foot sensation, skin condition, toe deformity, cramping, standing confidence and falls-risk context. A lower score may be useful information, but it should not be interpreted without functional assessment.

Athletes and sport clients

Consider running, jumping, cutting, landing, balance, footwear and sport-specific foot loading. The result can support a broader foot and ankle profile but does not determine readiness.

Workplace and manual task clients

Consider prolonged standing, walking surfaces, footwear, stairs, ladders and carrying demands. Do not use one toe-grip score to clear work duties.

Clients with foot symptoms

Pain, altered sensation, toe deformity, cramping and guarding may influence the result. Record symptoms carefully and compare with related findings.

Higher body mass clients

Absolute force and force relative to body mass may both be useful. Interpret the result in relation to goals, symptoms, foot loading and function.

Reliability, Validity and Measurement Considerations

Repeatability improves when the same setup is used each time.

Record and standardise:

• same body position
• same side tested
• same paper or card type
• same paper width
• same paper placement
• same hallux inclusion or exclusion
• same foot position
• same surface
• same pulling direction
• same pulling speed
• same endpoint
• same number of trials
• same scoring method
• same symptom and compensation recording

Enhanced paper-grip research supports the general idea of quantifying toe-grip force, but most published evidence is stronger for hallux grip than lesser-toe-specific testing. The Muscle Meter result should therefore be interpreted as protocol-specific.

Common Errors and Limitations

Common errors include:

• inconsistent paper placement
• including the hallux unintentionally
• different paper material
• pulling too quickly
• changing pull direction
• allowing the foot to slide
• allowing heel lift
• allowing whole-foot gripping
• not recording skin or toe symptoms
• comparing different protocols directly
• treating the score as a diagnosis

Limitations include:

• testing is setup-dependent
• paper friction affects results
• toe contact area affects results
• lesser-toe isolation can be difficult
• pain or altered sensation can reduce performance
• the test does not isolate one muscle
• universal Muscle Meter norms may be limited
• the result does not determine balance, gait, sport or work readiness on its own

Practical Applications

The Paper-Grip Test – 2–5 Toes [Muscle Meter] may be useful for:

• establishing a baseline lesser-toe grip score
• comparing right and left feet
• comparing lesser-toe grip with hallux grip
• tracking change over time
• reviewing force relative to body weight if directly calculated
• supporting foot and ankle assessment
• comparing with balance, calf strength, ankle mobility and gait
• educating the client about measurable progress
• reviewing walking, running, sport, work or daily-life demands

Ideas to Make the Result Better

If force is low on both sides, consider assessing toe mobility, foot sensation, hallux grip, calf capacity, ankle mobility, balance, gait and footwear.

If one side is much lower, compare with symptoms, previous injury, foot posture, balance and walking or running observations.

If cramping limits the result, record the response and consider shorter efforts, more rest or a gentler familiarisation trial.

If the hallux keeps assisting, separate the 1st-toe and 2–5 toes protocols clearly and document whether separation was successful.

If force improves over time, keep the same setup and monitor whether toe grip, symptoms, confidence and function improve together.

Recommended Standard Protocol Summary

Position: Seated, barefoot, foot flat on a consistent surface
Start position: Paper/card placed under the plantar surface of toes 2–5, hallux excluded where possible
Joint or trunk angle: Record knee angle, foot position and weight-bearing condition
Trials: 1 practice trial, then 2–3 recorded trials
Contraction duration: Pull until paper/card is removed or endpoint is reached
Rest: Brief rest between efforts as needed
Metric: Peak force required to remove paper/card; percentage of body weight only if directly calculated
Attachment or device setup: Paper/card connected to the Muscle Meter and pulled in a consistent direction
Final score: Best trial or average of trials
Key retesting requirement: Same paper/card, placement, position, pull direction, scoring method and symptom recording

FAQs

What does the Paper-Grip Test – 2–5 Toes measure?

It measures how much force the lesser toes can resist while gripping a paper or card.

Is it the same as the 1st-toe paper-grip test?

No. The 1st-toe test focuses on the hallux. This version focuses on toes 2–5 and should be recorded separately.

Should the hallux be included?

Usually no, unless your protocol specifically includes it. For this version, document whether the hallux was excluded successfully.

Should the result be recorded as percentage of body weight?

It can be if calculated directly from force and body weight. Use it for baseline, side-to-side comparison and retesting rather than as a universal target.

Are there universal Muscle Meter norms for this test?

Published Muscle Meter-specific universal norms for this exact 2–5 toes setup may be limited. Baseline and retest comparison are usually more useful.

Can this test diagnose balance problems or falls risk?

No. It can provide useful foot-strength context, but it does not diagnose balance impairment or predict falls on its own.

What can make the result unreliable?

Different paper placement, paper type, pull direction, foot position, hallux assistance, skin condition, pain, cramping and inconsistent instructions can affect results.

What should be recorded in Measurz?

Record side, toes tested, paper type, position, peak force, bodyweight percentage if calculated, symptoms, compensations and retest conditions.

Key Takeaways

• The Paper-Grip Test – 2–5 Toes [Muscle Meter] measures lesser-toe paper-grip force.
• Peak force is usually the main routine metric.
• The test is sensitive to paper type, placement, pull direction, hallux assistance and foot position.
• Percentage of body weight should only be used when directly calculated.
• Baseline comparison, side-to-side comparison and retesting consistency are usually more useful than broad norms.
• Measurz should capture setup, symptoms, force value, bodyweight-normalised values where calculated and retesting conditions.

References

Chatzistergos, P. E., Healy, A., Balasubramanian, G., Sundar, L., Ramachandran, A., & Chockalingam, N. (2020). Reliability and validity of an enhanced paper grip test; a simple clinical test for assessing lower limb strength. Gait & Posture, 81, 120–125. https://doi.org/10.1016/j.gaitpost.2020.07.011

Tsepis, E., & colleagues. (2023). Reliability and clinical applicability of lower limb strength using an enhanced paper grip test. Biology and Medicine.

Staffordshire University Centre for Biomechanics and Rehabilitation Technologies. (n.d.). Enhanced Paper Grip Test. Staffordshire University.