The stepping sequence, a stopwatch, best of two trials and published fall-risk cut-offs.
The FSST times how quickly someone steps forward, sideways and backward over four canes on the floor. It tests dynamic balance and quick changes of direction, and is recommended by the Academy of Neurologic Physical Therapy for vestibular disorders and Parkinson’s disease (stages 2 to 4). It takes under 5 minutes and needs four canes and this timer.
Stand close enough to help, keep the area clear and stop if the person feels dizzy, unsteady or has pain. Use a gait belt if your setting calls for one.
Lay four canes (or similar low sticks, about 1 inch high) flat on the floor in a plus sign to make four squares. Number them: the person starts in Square 1, facing Square 2 in front; Square 4 is to their right, and Square 3 is diagonally ahead to the right.
Stepping order (face forward the whole time)
Clockwise: 1 → 2 (forward) → 3 (right) → 4 (back) → 1 (left)
Then back the other way: 1 → 4 (right) → 3 (forward) → 2 (left) → 1 (back)
This is a measurement, not a diagnosis. The FSST shows how quickly someone can step in different directions. It can’t tell you why, or what treatment is needed. Results should be reviewed with a physical therapist or another licensed health care provider who examines the person.
Reference values, not pass/fail rules. The numbers below come from specific published study groups. Use them as a guide alongside your own examination.
Lower is better. Published cut-offs (as listed by the Shirley Ryan AbilityLab, with the Parkinson’s value from the original paper):
Sources. Shirley Ryan AbilityLab, Rehabilitation Measures Database: Four Square Step Test (cost: free). Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002;83(11):1566-1571. Duncan RP, Earhart GM. Four Square Step Test performance in people with Parkinson disease. J Neurol Phys Ther. 2013;37(1):2-8. Whitney SL, et al. Arch Phys Med Rehabil. 2007;88(1):99-104. Blennerhassett JM, Jayalath VM. Arch Phys Med Rehabil. 2008;89(11):2156-2161. Dite W, et al. Arch Phys Med Rehabil. 2007;88(1):109-114. Instructions on this page are written in our own words. Holsman Physical Therapy is not affiliated with these organizations, and they do not endorse this website.
Next step: Bring this printout to your next visit, or attach it to your referral. Holsman physical therapists treat balance, strength and walking problems at 17 clinics in North Jersey, the Bronx and Brooklyn, plus in-home visits. Request an appointment or call 1-855-465-7626. No referral needed to start with most plans; we verify your insurance free.
The Four Square Step Test (FSST) times how quickly a person can step forward, sideways and backward over four low canes laid on the floor in a plus shape. It tests dynamic balance and quick changes of direction. It was developed by Dite and Temple in 2002.
After a demonstration and one practice, the person does two timed trials. The better (faster) of the two times, in seconds, is the score.
In community-dwelling adults over 65, more than 15 seconds identified people at risk of multiple falls (Dite & Temple, 2002). Other cut-offs: more than 9.68 seconds in Parkinson’s disease (Duncan & Earhart, 2013), more than 12 seconds with vestibular disorders (Whitney et al., 2007), and more than 24 seconds after transtibial amputation (Dite et al., 2007).
Repeat the trial. A trial does not count if the person touches a cane, loses balance, or doesn’t get both feet into each square. If they can’t complete a trial, record that.
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