More on Hoover’s paresis test

Although I have had the occasional opportunity to elicit Hoover’s sign in patients with suspected
non-organic lower limb weakness, I had never fully understood the principle of this simple test.1 It
relies on Sherrington’s crossed extensor reflex: extension of one hip causes flexion at the
contralateral hip; this enables normal walking, and is retained even in decorticate animals. The test
can be performed in two ways:

1. Hip extension – In the first step, the examiner places his hand under the patient’s ankle on
the affected side and asks the patient to press down, to test voluntary hip extension. In the
second step, the examiner asks the patient to raise the contralateral (unaffected) leg, to test
involuntary extension on the affected side. In patients with non- organic weakness voluntary
extension is weak but Sherrington’s reflex ensures normal involuntary extension.
2. Hip flexion – In a reversal of the extension test, the examiner places his hand under the
patient’s ankle on the unaffected side and asks the patient to flex the hip on the affected
side. Lack of effort in non- organic weakness results in poor downward pressure in the good
leg.

A variation of Hoover’s test involves testing involuntary hip flexion on the affected side wherein the
patient, in the prone position, is asked to extend the hip on the unaffected side. Hoover’s test has
also been described in the upper limbs: flexion against resistance of an out- stretched arm results in
involuntary extension in the contralateral arm.

Akheel A Syed

References

1. Stone J, Zeman A, Sharpe M. Functional weakness and sensory disturbance. J Neurol Neurosurg
Psychiatry 2002 73: 241-245 [PubMed]

Originally published as a Rapid Response on bmj.com 2004 Apr 16 [WebCite]