Ankle Orthopaedic Test: Supination Resistance Test

The Supination Resistance Test estimates how much external force is required to initiate supination of the foot while the client stands in weight-bearing. It is commonly used in foot and ankle biomechanics to help understand how easily or difficultly the foot can be moved into a more supinated position.

A higher resistance finding may suggest greater external force is required to supinate the foot and may be associated with medial foot and ankle loading demands. A lower resistance finding may suggest the foot supinates more easily and may be relevant in some lateral ankle presentations. However, the test does not diagnose any condition on its own and should be interpreted with history, symptoms, foot posture, strength, gait and other assessment findings.

Introduction

The Supination Resistance Test is a foot and ankle special test used to estimate the amount of force required to supinate the foot in standing. It can be performed manually or with a measurement device that quantifies the force.

The test is often used in podiatry, biomechanics, foot orthosis reasoning and lower-limb assessment. It may provide information about how much external force is needed to initiate a supination movement of the rearfoot and midfoot while the foot is loaded.

In modern research, instrumented versions of the Supination Resistance Test are being studied in relation to foot and ankle biomechanics, posterior tibial tendon dysfunction, plantar fasciopathy, chronic ankle instability and foot orthoses. This makes it a useful test for assessment reasoning, but it should still be interpreted carefully.

The Supination Resistance Test should not be used as a stand-alone diagnostic test. A high or low result may support assessment reasoning, but it does not confirm or exclude pathology.

Quick Summary

Test name: Supination Resistance Test
Region: Foot and ankle
Primary purpose: Estimate force required to initiate foot supination in standing
Commonly associated presentations: Posterior tibial tendon dysfunction, plantar fasciopathy, chronic ankle instability, foot posture assessment, foot orthosis reasoning
Positive finding: Increased or decreased resistance compared with expected presentation, opposite side or reference context
Negative finding: Resistance appears within expected range and is not meaningfully different from the comparison side or relevant reference context
Best used with: Foot Posture Index, gait observation, Jack’s Test, heel raise testing, calf strength, balance and symptom history
Main limitation: It is not a stand-alone diagnostic test.

What Is the Supination Resistance Test?

The Supination Resistance Test estimates the external force needed to initiate supination of the foot in weight-bearing.

In the manual version, the professional places the fingers under the medial side of the foot, often near the navicular region, and applies an upward force to begin supinating the foot. The professional then rates the resistance subjectively.

In instrumented versions, a strap and force device are used to quantify the amount of vertical force required to initiate hindfoot inversion or foot supination. This may be reported in Newtons or as a percentage of body weight.

The test can provide insight into how difficult it is to move the loaded foot towards supination.

Why It Is Used

The Supination Resistance Test may be used to support assessment reasoning around:

• Foot posture
• Subtalar joint axis-related mechanics
• Load on structures contributing to internal supination moments
• Posterior tibial tendon dysfunction presentations
• Plantar fascia-related presentations
• Chronic ankle instability presentations
• Foot orthosis reasoning
• Wedging and footwear discussions within professional scope
• Side-to-side differences
• Monitoring changes over time

The test may help professionals understand whether the foot appears relatively easy or difficult to supinate when loaded.

What It Assesses

The test assesses the resistance of the foot to external supination force during standing.

It may provide information about:

• Supination resistance
• Side-to-side difference
• Foot stiffness or mobility context
• Potential tissue loading context
• Relationship to foot posture
• Relationship to foot orthosis response
• Differences between medial and lateral foot/ankle presentations

It does not directly assess:

• Tendon integrity
• Ligament integrity
• Plantar fascia structure
• Imaging findings
• Pain source
• Foot strength
• Balance
• Gait mechanics with certainty
• Diagnosis
• Readiness for sport or work

Who It Is Useful For

The Supination Resistance Test may be useful for clients with:

• Medial foot or ankle symptoms
• Posterior tibial tendon dysfunction-type presentations
• Plantar heel symptoms
• Chronic ankle instability-type presentations
• Pronated or supinated foot posture
• Foot orthosis or footwear assessment needs
• Lower-limb loading concerns
• Sport or work tasks involving repeated foot loading

It may also be useful for professionals learning tissue-stress reasoning and foot biomechanics.

When to Use This Test

Consider using the Supination Resistance Test when:

• Foot posture may be relevant to symptoms or movement
• You want to compare right and left foot supination resistance
• Posterior tibial tendon load is part of the assessment reasoning
• Chronic ankle instability is being considered within a broader assessment
• Foot orthosis reasoning is relevant
• You are tracking response to footwear, orthosis or load changes
• You want to add mechanical context to gait and movement observations

When Not to Use or When to Be Cautious

Use caution or avoid the test when:

• The client cannot stand safely
• Weight-bearing is highly painful
• There is acute foot or ankle trauma
• There is suspected fracture or acute inflammatory flare
• The client has severe foot sensitivity
• The test reproduces sharp or worsening symptoms
• The professional cannot apply force safely or consistently
• The client is unable to relax the foot during testing

Stop if the client reports sharp pain, cannot tolerate the position, or actively resists the test.

Equipment Required

For the manual version:

• No special equipment
• Measurz app
• Pain scale
• Notes field for qualitative scoring

For an instrumented version:

• Validated supination resistance measurement device
• Non-stretch strap
• Force gauge
• Flat testing surface
• Measurz app
• Body weight value if reporting percentage of body weight

Step-by-Step Protocol / Practice

Setup

Ask the client to stand barefoot on a flat surface. The feet should be in a natural relaxed stance.

Record whether the test is:

• Manual
• Instrumented
• Barefoot
• In footwear
• With or without orthoses
• On a level surface
• On a wedged or inclined surface

For standard testing, use barefoot standing on a level surface.

Client position

The client stands with:

• Feet in natural stance
• Weight evenly distributed
• Knees relaxed
• Hips facing forward
• Eyes looking forward
• Arms relaxed or lightly supported if needed

The client should not actively assist or resist the movement.

Examiner/professional position

The professional positions themselves beside or slightly in front of the tested foot.

They should be able to:

• Apply vertical force safely
• Observe the rearfoot
• Feel or measure the start of supination
• Compare sides
• Ask about symptoms

Hand placement

For the manual version, place the index and middle fingers under the medial side of the foot, commonly near the navicular region, and apply upward vertical force.

For an instrumented version, place the strap according to the device protocol, commonly passing under the foot from the lateral region towards the medial midfoot/navicular region.

Stabilisation

Do not manually hold the foot in a corrected position.

The goal is to measure or estimate resistance, not to force a correction.

Movement or force direction

Apply upward vertical force to initiate foot supination or hindfoot inversion.

The force should be smooth and gradual.

Instructions

Tell the client:

“Stand relaxed and try not to help or resist the movement. I am going to apply an upward force under your foot to see how much resistance there is to initiating supination. Tell me if this reproduces any symptoms.”

Positive finding

A positive or meaningful finding depends on the clinical question.

Examples include:

• High resistance compared with the opposite side
• Low resistance compared with the opposite side
• Marked difference from expected response
• Symptom reproduction during the test
• High resistance in a medial foot or ankle presentation
• Low resistance in a lateral ankle instability presentation
• Large change when tested with footwear, orthoses or wedging

The direction of significance must be interpreted in context.

Negative finding

A negative or unremarkable finding may include:

• Similar resistance side to side
• No relevant symptom reproduction
• Resistance appears consistent with the client’s profile
• No meaningful difference with the assessment condition being tested

A negative result does not exclude foot or ankle pathology.

Stopping criteria

Stop if:

• Pain increases sharply
• The client cannot tolerate standing
• The client actively resists or assists
• The foot cannot be safely moved
• Balance becomes unsafe
• Symptoms become concerning

Safety notes

The test should be controlled. Avoid sudden force, excessive pulling or repeated painful testing.

Positive and Negative Test Interpretation

A high Supination Resistance Test finding may suggest that more external force is required to initiate supination of the loaded foot. This may be associated with greater demand on structures that help generate internal supination moments, such as the posterior tibial tendon and related medial foot structures.

A low finding may suggest that the foot supinates more easily. In some presentations, this may be relevant when considering lateral ankle instability or reduced resistance to inversion/supination movement.

However, neither high nor low resistance confirms a condition. Supination resistance is influenced by body mass, foot posture, subtalar joint axis position, tissue stiffness, symptoms, guarding, stance and testing method.

A negative or unremarkable test may suggest that supination resistance does not appear to be a major distinguishing feature in that session. However, it does not exclude foot or ankle pathology.

The result is more meaningful when interpreted with:

• Symptom history
• Pain location
• Foot posture
• Foot Posture Index
• Gait
• Heel raise testing
• Calf strength
• Balance
• Hop testing
• Jack’s Test
• Orthosis or footwear response
• Activity demands

Sensitivity, Specificity and Diagnostic Accuracy

At the time of writing, high-quality peer-reviewed diagnostic accuracy evidence reporting sensitivity, specificity and likelihood ratios for the Supination Resistance Test as a stand-alone diagnostic test appears limited.

This means the test should be used as an assessment reasoning and biomechanical profiling tool rather than as a stand-alone diagnostic test.

Relevant evidence includes:

• Research has shown that supination resistance differs across some foot and ankle musculoskeletal presentations.
• In a 2023 case-control study, participants with chronic ankle instability showed lower supination resistance on the injured foot compared with the healthy foot.
• The same study found that participants with posterior tibial tendon dysfunction showed greater supination resistance on the injured foot compared with the healthy foot.
• No significant between-foot difference was observed for plantar fasciopathy or healthy controls in that study.
• Supination resistance increased with valgus surface inclination and decreased with varus surface inclination.
• These findings support biomechanical relevance but do not provide stand-alone sensitivity, specificity or likelihood ratios for diagnosis.

Because formal diagnostic accuracy values are limited, professionals should document the finding descriptively and interpret it cautiously.

Reliability and Validity

Evidence suggests that instrumented versions of the Supination Resistance Test can demonstrate good to excellent reliability when performed with a validated device and standardised method.

Manual testing may be more subjective and depends on professional experience. Reliability may improve when the same professional uses a consistent scale and clear criteria.

Validity evidence supports the test as a measure related to the force required to supinate the foot in static standing. Research also suggests relationships between supination resistance, subtalar joint axis position, and some aspects of foot and ankle biomechanics.

However, the test should not be treated as a direct measure of tissue pathology or dynamic gait load in all situations. Static standing is not the same as walking, running or sport performance.

Reliability improves when the professional standardises:

• Barefoot or footwear condition
• Standing posture
• Foot position
• Force direction
• Force speed
• Device or hand placement
• Number of trials
• Symptom recording
• Side-to-side comparison

Common Errors and Limitations

Common errors include:

• Applying force too quickly
• Pulling diagonally instead of vertically
• Allowing the client to help or resist
• Not recording barefoot versus footwear condition
• Not comparing sides
• Not recording symptoms
• Calling the test diagnostic
• Treating manual resistance as a precise measurement
• Not accounting for body mass
• Not recording orthoses or wedging conditions

Limitations include:

• Manual testing is subjective
• Static testing may not reflect dynamic gait
• Body mass influences resistance
• Foot posture alone does not explain all results
• Instrumented devices may not be available
• Diagnostic accuracy values are limited
• High or low resistance does not confirm pathology
• The test should not be used alone for decision-making

Practical Applications

The Supination Resistance Test may be useful for:

• Foot and ankle biomechanical profiling
• Side-to-side comparison
• Posterior tibial tendon dysfunction-type assessment reasoning
• Chronic ankle instability-type assessment reasoning
• Plantar fascia load reasoning
• Foot orthosis and footwear discussions within scope
• Monitoring response to load or external support changes
• Educating clients about foot mechanics
• Supporting Measurz foot and ankle reports

In Measurz, it can be recorded alongside Jack’s Test, Foot Posture Index, heel raise testing, calf strength, ankle range of motion, balance, hop testing and gait observations.

How to Record This in Measurz

Record the following:

• Test name: Supination Resistance Test
• Side tested
• Result: high, low, expected, unclear or unable to test
• Manual or instrumented method
• Force value if measured
• Percentage of body weight if calculated
• Barefoot or footwear condition
• Orthoses or wedges used, if any
• Client position
• Foot position
• Force direction
• Number of trials
• Symptom location
• Pain score
• Symptom quality
• Side-to-side comparison
• Confidence in result
• Irritability
• Compensations
• Reason for stopping, if relevant
• Related findings
• Assessment interpretation notes
• Retest date if relevant

Recording these details improves repeatability, communication, client education, assessment reasoning, team consistency and reporting quality.

Related Tests / Internal Links

• Jack’s Test
• Foot Posture Index
• Navicular Drop Test
• Single-leg heel raise
• Calf raise endurance test
• Ankle dorsiflexion range of motion
• Balance testing
• Hop testing
• Gait observation
• Posterior tibial tendon assessment
• Plantar fascia assessment

FAQs

What does the Supination Resistance Test measure?

It estimates how much external force is required to initiate supination of the foot in standing.

Is the test diagnostic?

No. It may support assessment reasoning, but it does not diagnose a condition on its own.

What does high supination resistance mean?

High resistance may suggest that more force is required to supinate the foot. This may be relevant in some medial foot and ankle presentations, but it needs context.

What does low supination resistance mean?

Low resistance may suggest the foot is easier to supinate. This may be relevant in some lateral ankle instability presentations, but it does not confirm anything on its own.

Is the manual test objective?

The manual test is subjective. Instrumented versions can quantify force more objectively.

Should both feet be tested?

Yes. Side-to-side comparison is often useful.

Can footwear or orthoses change the result?

Yes. Footwear, orthoses and wedging can alter supination resistance, so testing conditions must be recorded.

Should pain be recorded?

Yes. Record pain location, pain score and symptom quality during the test.

Key Takeaways

The Supination Resistance Test estimates the force required to initiate foot supination in standing.

It may support assessment reasoning around foot mechanics, tissue loading and orthosis considerations.

High or low resistance findings must be interpreted in context.

Diagnostic accuracy values for the test as a stand-alone diagnostic tool are limited.

Instrumented testing is more objective than manual testing.

The result should be recorded carefully and interpreted alongside other Measurz assessment findings.

References

Griffiths, I. B., & McEwan, I. M. (2012). Reliability of a new supination resistance measurement device and validation of the manual supination resistance test. Journal of the American Podiatric Medical Association, 102(4), 278–289.

Moisan, G., Chicoine, D., McBride, S., Farahpour, N., Isabelle, P. L., Dagenais, C., & Griffiths, I. (2023). Supination resistance variations in foot and ankle musculoskeletal disorders: Implications for diagnosis and customised interventions with wedged insoles. Journal of Foot and Ankle Research, 16, 91. doi:10.1186/s13047-023-00681-5

Moisan, G., Isabelle, P. L., Gómez-Carrión, Á., Chicoine, D., Farahpour, N., Dami, A., Reguera-Medina, J. M., McBride, S., & Griffiths, I. (2026). Establishing normative values for the Supination Resistance Test: An international cross-sectional study. Journal of Foot and Ankle Research, 19(1). doi:10.1002/jfa2.70137

Payne, C. B., Munteanu, S. E., & Miller, K. (2003). Position of the subtalar joint axis and resistance of the rearfoot to supination. Journal of the American Podiatric Medical Association, 93(2), 131–135.

Payne, C. B., Oates, M. J., & Noakes, H. (2003). Static stance response to different types of foot orthoses. Journal of the American Podiatric Medical Association, 93(6), 492–498.