Toe Touch Test
The toe touch test has been used as a crude measure of flexibility for many years. In this article, we’ll dissect the pros and cons of the toe touch test, including how to perform the assessment correctly.
Flexibility is broadly defined as the total range of motion around a joint.
For example, the knee is a synovial (synovial fluid containing) hinge joint responsible for flexion and extension in the lower leg. Starting from complete extension (0° or leg fully straightened out) the knee should be able to fully flex to around 155°. In other cases, the knee may not be able to fully extend back to 0°. Either scenario characterises reduced flexibility at the knee joint.
Reduced flexibility is linked with:
- Joint pain as shortened muscles and reduced blood supply can compress nerves
- Increased injury risk as shortened muscles and stiffer connective tissues are more likely to be strained and/ or tear during movement
- Postural conditions as tightness in one area of the body (e.g., hip) often requires adverse compensations in others (e.g., lower back), resulting in conditions like lordosis, kyphosis, and scoliosis
- Compensatory movements as tightness in one muscle and/ or joint (e.g., ankle) can result in adverse pressure being placed on another joint (e.g., knee) potentially resulting in chronic injury
- Reduced training adaptation as tightness/ stiffness will prohibit an individual from training through a complete range of motion, inhibiting training adaptations, especially muscle hypertrophy
- Reduced cardiovascular function like reduced blood flow and endothelial function, as well as increased arterial stiffness and blood pressure
Nevertheless, a joint having too much flexibility (hyper flexibility) can also be an issue. For example, knee hyperextension characterises a knee joint that can extend beyond full extension or 0°. Knee hyperextension is an unnatural position, whereby the joint is inadequately supported by muscles and connective tissues (tendon & ligaments etc), which can increase the risk of knee injury.
Therefore, adequate joint flexibility is required to ensure a particular joint remains stable, injury/pain free, and does not require compensatory inputs.
Inadequate flexibility is often characterised through people reporting symptoms like tightness, stiffness, and pain in various muscles and joints throughout the body. However, these do not actually test joint range of motion. People also often lack the appropriate equipment or knowledge of how to accurately assess flexibility.
Therefore, we require a comprehensive flexibility assessment, that is easy to administer and simple to interpret. This is where the toe touch test comes in.
What is the Toe Touch Test?
The toe touch test is a counterpart of the sit and reach test, and involves maximally reaching down to the floor from a stood position. This assesses flexibility, primarily in the posterior muscular chain (hip, hamstrings and glutes), but also the lumbar spine (erector spinae, multifidus, and quadratus lumborum) and shoulders (deltoid and latissimus dorsi) to a lesser extent.
Different synovial joints (hinge, ball and socket, etc) move through different planes and have different ranges of motion. Therefore, the major limitation of the toe touch test is that whole-body flexibility is dependent upon a lot more muscles and joints than the hips, lumbar spine, and shoulders alone.
However, comprehensively assessing whole-body flexibility would involve tediously assessing range of motion via goniometry, in each of the body’s 300 individual joints. Until an alternative is rigorously validated and approved the toe touch test is still the most viable option, despite its inherent limitations. As such, the toe touch test is considered an accurate, reliable, and valid indicator of flexibility.
General Factors Affecting Toe Touch Test Performance
- Age: There is an age-related reduction in the quality and quantity of elastic muscle tissue (e.g., titin and elastin), gradually reducing flexibility
- Gender: Women have slightly greater flexibility compared to men, primarily due to hormonal and specific anatomical (medially exaggerated hip architecture) differences
- Bodyweight/composition: Individuals with a higher body mass index and/ or higher body fat percentage typically have reduced flexibility compared to individuals of a lower weight status
- Genetics: Individuals born with certain genotypes have connective tissue that is more compliant (stretches upon loading) leading to enhanced flexibility
- Training status: Flexibility can be improved with flexibility training (stretching etc). Aerobic and resistance training improve flexibility by similar magnitudes
- Sedentary behaviour: Remaining seated for long periods of time can cause reduced muscle length and reduced flexibility. This is especially the case for the hip flexors and thoracic spine
- Disease: Individuals suffering from various types of muscular dystrophy are likely to experience reduced flexibility
- Recent injury: Chronic injuries like osteoarthritis, fracture, and connective tissue tears, can inhibit flexibility due to joint alteration and scar tissue accumulation
How to Perform the Toe Touch Test
The toe touch assessment (otherwise known as the fingertip to toe test) is a free, simple, and easier-to-administer alternative to the sit and reach test.
To account for differences in flexibility, three separate versions of the toe touch test are proposed. These primarily differ regarding the height of the starting surface the participant begins the test stood upon, and cover beginner, intermediate, and advanced levels of flexibility.
Toe touch test 1 (Beginner): This test will be appropriate for the majority of individuals simply wishing to assess flexibility. There is no additional equipment required, as the participant should simply aim to touch the floor.
Toe touch test 2 (Intermediate): This test will be appropriate for those wishing to assess if their flexibility has improved. A 15-20cm elevated platform is required, such as the first step on a set of stairs or a low exercise stepper. The participant should aim to reach past their toes.
Toe touch test 3 (Advanced): This test will be appropriate for those wishing to assess drastic improvements in their flexibility. A 20-30cm elevated platform is required, such as a high exercise stepper or exercise box. The participant should aim to reach as far past their toes as possible.
For an individual who achieves the maximum reaching distance on a given level, they should be encouraged to progress onto a more challenging version.
Once an appropriate version has been selected, the general instructions are as follows:
- The participant should engage in a warm-up prior to the test involving light cardio movements (jogging on the spot, bum kicks, hip circles etc), and light dynamic stretches (submaximal reaches for the ceiling, knees, then toes etc) before the test begins
- The participant then begins by standing upright on their respective starting surface (see versions above) ideally barefoot or at least without shoes on
- The participant should then exhale, and slowly reach down as far as possible, holding this position momentarily
- The distance to/from the ground at which the middle index finger (of either hand) reaches lowest should be recorded
- Throughout the entire test the participant should keep their knees straight, toes pointing forward, and hands together. Any attempts that violate these instructions are not counted. The head is permitted to drop between the arms for the best stretch
- The test should be repeated 2-3 times (allowing ~60s rest in-between) and the average score recorded
Ideally, the point of maximal stretch should be determined with a tape measure by a partner. However, if a partner is unavailable, the participant may roughly mark the maximal distance reached with a pen, and measure the distance to/ from the ground.
Important note: The participant should be aware reaching toward the floor does increase the risk of a forward fall. Appropriate control measures should be put in place, such as resting between attempts, soft flooring/ mats, or performing the test in the presence of another person for assistance.
Factors Affecting Toe Touch Test Performance
Warm up: The warm-up exercises used should be standardised between assessments, ensuring levels of muscle activation and heat production are matched
Footwear: Footwear should be kept the same between assessments (ideally barefoot) to match any flexibility assistance footwear may give
Environment: Flexibility is greatest when muscles are warm, so scores recorded in warmer/ colder conditions should take the ambient temperature into account
Time of day: Typically, muscles are more flexible and connective tissues more compliant in the evening compared to the morning
Balance demand: Participants tend to hold back reaching maximally due to fear of a forward fall, especially in those with poor balance. Strategies could be employed to minimise the risk of a forward fall (partner support etc)
All such factors should ideally be kept the same between assessments.
Classification of Toe Touch Test Performance
The toe touch test is a great indicator of general flexibility. However, flexibility in this context broadly refers to the passive range of motion, or the range a joint can be passively (independent of muscular contraction) moved through. Active range of motion, on the other hand refers to the range a joint can actively (in the presence of muscular contraction) be moved through.
Active range of motion, together with further assessments like muscle activation, joint mobility, movement competency, and technical ability, are far more predictive of adverse outcomes like injury risk, functional ability, and musculoskeletal pain. These should ideally be employed alongside passive range of motion assessments.
Nevertheless, the toe touch test should still be viewed as an initial screening tool, but not the definitive measure of flexibility. Toe touch performance should be used to assess general flexibility progress (year to year), and maintaining adequate flexibility as people age.
The following categories categorise toe touch performance dependant on gender.
Toe Touch Test Categories
Male
| Test Type | Equipment Required | Male | |
|---|---|---|---|
| Toe Touch Test 2 (Advanced) | Raised Platform (20-30cm) | Outstanding | > 27 |
| Excellent | 17-26 | ||
| Toe Touch Test 1 (Intermediate) | Raised Platform (15-20cm) | Good | 6-16 |
| Average | 0-5 | ||
| Standard Toe Touch Test Assessment | Floor | Fair | -1--8 |
| Poor | -20--9 | ||
| Very Poor | < -20 | ||
| Distance from the ground (cm) | |||
Female
| Test Type | Equipment Required | Female | |
|---|---|---|---|
| Toe Touch Test 2 (Advanced) | Raised Platform (20-30cm) | Outstanding | > 30 |
| Excellent | 21-29 | ||
| Toe Touch Test 1 (Intermediate) | Raised Platform (15-20cm) | Good | 11-20 |
| Average | 1-10 | ||
| Standard Toe Touch Test Assessment | Floor | Fair | -7-0 |
| Poor | -15--8 | ||
| Very Poor | < -15 | ||
| Distance from the ground (cm) | |||
Note: The toe touch test is intended as a broad indicator of overall body flexibility, and should be used as an initial screening tool. Diagnosis of poor flexibility should only be made by a suitably trained medical professional or physiotherapist, following suitably validated assessments.
Sources
Scientific publications
Siqueira CM, Rossi A, Shimamoto C, Tanaka C. Balance highly influences flexibility measured by the toe-touch test. Hum Mov Sci. 2018 Dec;62:116-123. doi: 10.1016/j.humov.2018.10.001. Epub 2018 Oct 6. PMID: 30300805.
Nuzzo JL. The Case for Retiring Flexibility as a Major Component of Physical Fitness. Sports Med. 2020 May;50(5):853-870. doi: 10.1007/s40279-019-01248-w. PMID: 31845202.
Kruse NT, Scheuermann BW. Cardiovascular Responses to Skeletal Muscle Stretching: “Stretching” the Truth or a New Exercise Paradigm for Cardiovascular Medicine? Sports Med. 2017 Dec;47(12):2507-2520. doi: 10.1007/s40279-017-0768-1. PMID: 28780647.
Ayala F, Sainz de Baranda P, De Ste Croix M, Santonja F. Absolute reliability of five clinical tests for assessing hamstring flexibility in professional futsal players. J Sci Med Sport. 2012 Mar;15(2):142-7. doi: 10.1016/j.jsams.2011.10.002. Epub 2011 Nov 21. PMID: 22104651.
Ekedahl H, Jönsson B, Frobell RB. Fingertip-to-floor test and straight leg raising test: validity, responsiveness, and predictive value in patients with acute/subacute low back pain. Arch Phys Med Rehabil. 2012 Dec;93(12):2210-5. doi: 10.1016/j.apmr.2012.04.020. Epub 2012 Apr 30. PMID: 22555005.
Robinson HS, Mengshoel AM. Assessments of lumbar flexion range of motion: intertester reliability and concurrent validity of 2 commonly used clinical tests. Spine (Phila Pa 1976). 2014 Feb 15;39(4):E270-5. doi: 10.1097/BRS.0000000000000131. PMID: 24253798.
Guariglia DA, Pereira LM, Dias JM, et al. Time-of-day effect on hip flexibility associated with the modified sit-and- reach test in males. International Journal of Sports Medicine. 2011 Dec;32(12):947-952. DOI: 10.1055/s-0031-1283182. PMID: 22052023.
Books
Baechle, T.R. and Earle, R.W. eds., 2008. Essentials of strength training and conditioning. (human kinetics).