Reliability and validity of the Four Square Step Test in patients with hip osteoarthritis before and after total hip replacement

  • M. Batting
    Corresponding author at: Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Headington, Oxford OX3 7HE, UK.
    Nuffield Orthopaedic Centre, Physiotherapy Research Unit, Headington, Oxford, UK

    University of Southampton, Health Sciences, Southampton, UK
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  • K.L. Barker
    Nuffield Orthopaedic Centre, Physiotherapy Research Unit, Headington, Oxford, UK

    Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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Published:October 15, 2018DOI:



      To determine the validity and inter- and intra-rater reliability of the Four Square Step Test (FSST) in assessing gait performance, balance and physical function for patients with hip osteoarthritis before and after total hip replacement (THR).


      Observational, repeated measures.


      A specialist orthopaedic hospital.


      Fifty-eight participants with moderate to severe hip osteoarthritis scheduled to receive primary hip replacement within 4 months from recruitment.

      Main outcome measure

      Time to complete the FSST, time and steps to complete the Figure of 8 Walk Test (F8W) and Berg Balance Scale score (BBS).


      The Bland and Altman limits of agreement for intra-rater measurements of the FSST were −3.2 s to 3.5 seconds before THR and −1.5 to 2.0 seconds after THR. Limits of agreement for two different raters were −2.2 to 3.4 seconds, all with small mean differences indicating little bias between raters or replications. Concurrent validity was assessed, and the FSST correlated highly with the F8W (r = 0.7, P< 0.001) and moderately with the BBS (r = 0.6, P < 0.001). Only one participant was rated as being at moderate risk of falls on the BBS, with the other participants scoring low; only one participant failed to complete the F8W. This is in contrast to the FSST, which 21 people failed to complete pre-operatively.


      The FSST is a valid and reliable measure of multi-directional stepping speed and balance, giving a more informative measure of gait performance than the F8W and BBS, and is feasible for use in a clinical population of patients both before and after THR.


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