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.
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.
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.
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
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.
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.
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.
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.”
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.
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
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.
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.
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
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.
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
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.
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
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.
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 is usually not needed for routine paper-grip testing.
Use only if a specific lever arm and biomechanical interpretation are intentionally included.
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 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.
Use only if a sustained gripping window is intentionally tested.
Use only if repeated or sustained toe-grip trials are part of the protocol.
Consider attention, coordination, foot size, task understanding and ability to isolate the lesser toes. Practice trials are useful.
Use the test for baseline foot-strength context, progress tracking and comparison with walking, running or gym goals.
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.
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.
Consider prolonged standing, walking surfaces, footwear, stairs, ladders and carrying demands. Do not use one toe-grip score to clear work duties.
Pain, altered sensation, toe deformity, cramping and guarding may influence the result. Record symptoms carefully and compare with related findings.
Absolute force and force relative to body mass may both be useful. Interpret the result in relation to goals, symptoms, foot loading and function.
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 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
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
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.
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
It measures how much force the lesser toes can resist while gripping a paper or card.
No. The 1st-toe test focuses on the hallux. This version focuses on toes 2–5 and should be recorded separately.
Usually no, unless your protocol specifically includes it. For this version, document whether the hallux was excluded successfully.
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.
Published Muscle Meter-specific universal norms for this exact 2–5 toes setup may be limited. Baseline and retest comparison are usually more useful.
No. It can provide useful foot-strength context, but it does not diagnose balance impairment or predict falls on its own.
Different paper placement, paper type, pull direction, foot position, hallux assistance, skin condition, pain, cramping and inconsistent instructions can affect results.
Record side, toes tested, paper type, position, peak force, bodyweight percentage if calculated, symptoms, compensations and retest conditions.
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.
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.
