Standing Toe Touch – Not Just A Lower Back Test!

Posted By: Andy Barker

When you use a standing forward flexion test or toe touch, what do you actually look for?



Quality of movement?

Probably all the above…hopefully.

You’d probably use this type of test for a patient reporting lower back pain, maybe hip or thoracic pain (joint below and above) but…

Would you use this test for a patient with shoulder or Achilles pain or with patella tendinopathy?

Probably not I’m guessing, but you should…100%.

You should assess the toe touch, and other big movements like trunk extension, side-flexion and rotation for EVERY patient you see.

These big movements tell you so much about how your patient is controlling their body, any possible restrictions they may have and any compensations they may have developed due to their injury.

Not only this…

If you notice big changes here, this is where you need to start, as these big changes will have the biggest and quickest affect on your patients symptoms.

Let me explain.

You see a patient with shoulder pain.

You probably start by assessing SHOULDER range of movement and maybe notice a restriction, maybe some pain with shoulder flexion for example.

You go through the rest of your assessment and maybe pick some reduced strength in a couple of positions and observe a scapula that is poorly positioned i.e ‘winging.’

So you get to work with your hands-on treatments and rehab to fix these problems…

Maybe some work around their pectorals to release these tissues to improve shoulder flexion on the bed…

And give some pectoral stretching as part of their home rehab programme.

You maybe go through a couple of scapula stability exercises to help with the ‘winging’ scapula.

All good, eh?

All seems to be going well until your a few sessions in and your patient stops progressing.

Maybe you have tried to progress their rehab but even some lower level exercises are bringing back their symptoms…

Or day-day activities are starting to aggravating them again.

If this is happening you have missed something.

What if that poor shoulder flexion pattern and poor scapula positioning is more of a thoracic spine issue?

This is quite common with shoulder injuries, particularly insidious onset injuries, where poor thoracic mobility is contributing towards this problem.

You might observe poor thoracic flexion when assessing the toe touch pattern.

The first part of the toe touch requires the thoracic spine to flex, then the ribcage to depress and retract, then the hips to flex.

But if you went straight to assessing shoulder range of movement you’d have missed this important bit of information.

You can do as much shoulder or scapula rehab as you like…

But if the main problem is the thoracic spine, unless you identity, and then fix this problem, then your patient was always going to struggle.

Using the same touch touch test you might notice a poor weight shift in the feet when reaching forwards.

This might be really important for a patient with a lower limb injury like Achilles or patella tendionopathy, hip impingement or recurrent hamstring injuries.

A posterior weight shift in the feet should happen when you reach forwards as your body manages your base of support to keep you balanced.

A lack of this posterior weight shift could indicate a number of things…

Including poor force transmission and control and could be the reason the muscles and joints of the lower limb are overloading and in turn causing any number of the problems mentioned before…and so many more. 

This is why simple tests like standing flexion (toe touch), extension, side-flexion and rotation are so important and are tests that you should be doing with every patient you see, regardless of their injury.

You should also observe every patient walking at the start of your assessment, regardless of whether they have neck or foot pain, or anything in between (I’ll save this for another blog).

These are the first two parts of the objective assessment.

These are the big tests you need to do before you even think about assessing range of movement, strength, observing and palpating and doing your special tests.

Miss the big stuff then you are just making things harder for yourself.

Identify and fix the big stuff first, the smaller problems usually get fixed up at the same time.

Focus too much on the small stuff, and the changes you make to patient symptoms and function, will be just that…


And more frustratingly for your and your patient…


Want to learn a better way to conduct a basic but brilliant objective assessment?

One that gives you all the information you need to nail your patient’s diagnosis and highlight all the key problems so you know exactly where to start with your treatments and rehab?

Then head here. (

The objective assessment is one of three introductory modules in my New Grad Physio Membership (the others are the subjective assessment and rehab planning).

Find out how to do the basics ‘brilliantly’ and get great patient results even as a fresh and inexperienced therapist.

Click here ( to find out more.