Noncomplex Type 2 diabetic patients often make up a substantial percentage of a Podiatrist's case load. While it is the standard procedure to carry out periodic checks using a monofilament and a doppler, intrinsic muscle testing isn’t always tested as standard. This paper investigates the validity of a simple test intended to highlight muscle weakness which could lead to deformity, ulceration and potentially falls.


Hallux plantar flexor strength in people with diabetic neuropathy: Validation of a simple clinical test

Healy, A.,  Naemi, R.,  Sundarb, L., Chatzistergos, P., Ramachandran, A., Chockalingam, N.  (2018)

Diabetes Research and Clinical Practice (144) pp 1-9



This research sought to test the validity of the “paper grip test” which was first used as a screening tool for intrinsic muscle weakness in leprosy. However, its use to assess intrinsic muscle strength for other conditions has been questioned due to the limited number of validation studies.

In this study, 69 patients with diabetic neuropathy were analysed using the paper grip test at the same time as a plantar pressure platform quantified the force under the hallux, and then with a hand-held dynamometer. The 69 patients were then divided into those who had passed and those who had failed the paper grip test and then males and females. Statistical analysis was then carried out between the groups and a “moderate positive correlation between the paper grip test and the hand-held dynamometer”.


What it all means:

This paper suggests that the paper grip test can be used as a valid clinical tool to quickly assess hallux plantarflexion strength for neuropathic diabetics.

Key points:

  • The participants in this study were all found to have weak hallux plantar flexor muscles.


  • “Grip force measured during paper grip test was higher for males than for females”.


  • The test found a positive correlation between the paper grip test and hand-held dynamometry test.


Putting it into practice:

  1. Intrinsic muscle weakness can affect a wide range of patients for a wide variety of reasons, but in diabetic patients, it can be indicative of changes which are occurring in the feet because of diabetes. Testing intrinsic muscle strength is equally as important as other routine tests such as the Monofilament test.
  2. Place a piece of paper or a business card under the patient’s hallux - your patient should be sitting not standing. Ask your patient to hold the card / paper while you try to pull it away.
  3. If intrinsic muscle weakness is found, early intervention can begin with foot exercises and / or foot orthoses.
  4. Always use this test in conjunction with other tests rather than in isolation.