Test: Hoover Test

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Background/Purpose

The Hoover Test or Hoover's sign is a clinical examination tool used to evaluate suspected non-organic leg weakness or to detect malingering and functional weakness in the lower extremities (OrthoFixar, 2025). First described by Dr. Charles Franklin Hoover in 1908, this test was originally designed as a bedside test to identify functional weakness in the lower extremities, though its original purpose was actually to diagnose mild cases of hemiparesis (Shams et al., 2012; Physiopedia). The test is based on the principle of synergistic contraction and the crossed extensor reflex, where involuntary extension of one leg normally accompanies flexion of the contralateral leg, as occurs naturally during walking (Wikipedia, 2025; Physiopedia). The test evaluates whether involuntary hip extension on the contralateral side occurs when the patient attempts voluntary hip flexion (Carepatron). In the course of routine use for physical and neurological examinations, it has also been found invaluable in the detection of functional neurological disorders, low back pain, sciatica, sciatic neuritis, or lumbosacral radiculitis, such as protruded lumbar intervertebral disk (Arieff et al., 1961). In a cohort study of 337 patients presenting with suspected stroke, Hoover's sign was found to be moderately sensitive (63%) and very specific (100%) for a diagnosis of functional weakness (McWhirter et al., 2011). A systematic review reported overall sensitivity of 94% and specificity of 99% for the test (Diagnosis of Functional Weakness, 2022).

Procedure

Patient Position:
The patient lies supine (on their back) in a relaxed position on the examination table (OrthoFixar, 2025; Wikipedia, 2025)
Both legs should be extended and relaxed initially
The patient should be comfortable and instructed to relax

Procedure:
Method 1 - Testing for Hip Flexion Weakness:

Examiner Position: The examiner stands at the foot of the table or bed with both hands cupping or positioned under the calcaneus (heel) of each leg (OrthoFixar, 2025; Physiopedia)
Initial Assessment: Ask the patient to attempt an active straight leg raise on the involved (weak) side while keeping the knee extended (OrthoFixar, 2025; Wikipedia, 2025)

Observe whether the patient can lift the leg
Note any effort or weakness observed

Assessment of Contralateral Extension: While the patient attempts to flex the hip and raise the "weak" leg, the examiner should feel for downward pressure (involuntary hip extension) under the heel of the opposite "normal" leg (OrthoFixar, 2025; Wikipedia, 2025)

If the patient is making an honest effort with organic weakness, the examiner should feel the normal limb's heel extending (pushing down) against their hand
This occurs as the patient involuntarily extends the contralateral hip to assist in the effort to flex the weak hip
Comparison: Both sides should be tested and compared for differences (OrthoFixar, 2025)

Method 2 - Testing for Hip Extension Weakness (Alternative):
If a patient reports weakness of hip extension and appears weak upon direct testing, place one hand behind the heel of the patient's weak leg and ask them to push against it (Wikipedia, 2025)

Initially, no movement may be felt

Ask the patient to raise the other leg (flex the contralateral hip) (Wikipedia, 2025)

The examiner should feel pressure on their hand as the patient involuntarily extends the weak hip
This can be pointed out to the patient in a non-confrontational manner

Seated Position Variation:
In the seated position (including in a wheelchair), ask the patient to press each leg alternately down into the chair with maximum force, with the examiner's hands placed under the leg being examined (Diagnosis of Functional Weakness, 2022)
Then ask the patient to lift each leg off the chair with the examiner's hand above the limb being lifted and below the contralateral limb (Diagnosis of Functional Weakness, 2022)

Important Notes:
If the lifted limb is weaker, pressure under the normal heel increases because of the increased effort to lift the weak leg off the examination table (OrthoFixar, 2025)
The patient may not be concentrating on flexing their sound hip when the examiner is testing the involuntary extension of the weak hip (Physiopedia)
Apraxia, a common neurological deficit, could explain failure to voluntarily extend the hip and complicate interpretation (Physiopedia)
Strong hip muscles can make the test difficult to interpret (Wikipedia, 2025)

A positive finding can indicate either organic weakness OR non-organic weakness, depending on the context:
Performed: Unilaterally

Dialog

The patient lies supine while the examiner cups both heels; when the patient attempts to raise the weak leg, the examiner assesses for involuntary downward pressure (hip extension) under the contralateral heel.

Criteria

• Increased contralateral heel pressure
• Leg lifts into air

Measurement

LOINC Code

Scale/Grading

selection range; grade - LOINC ID
Option - Value option selection range; grade - LOINC IDContralateral pressure, leg lifts = ; Pass - Contralateral pressure, no leg lifts = ; Fail - No contralateral pressure = ; Fail -