During the Hoover test, how is malingering differentiated?

• A. Downward force on the opposite leg is present when lifting the test leg.
• B. Downward pressure is absent when attempting to lift the leg.
• C. The patient reports pain during leg lift.
• D. The patient cannot lift the leg due to weakness.

Answer: (B)

Hoover’s sign hinges on whether real effort is being put into the leg lift by the patient. When you ask the patient to lift one leg, you also assess the opposite leg by feeling for downward pressure as they attempt the lift. If the patient is truly trying to lift with a weak leg, there will be little to no downward pressure on the opposite leg because the effort is not genuine, so the pressure cue is absent. Conversely, if the patient is malingering, they may simulate the movement but fail to generate true effort, and you still won’t detect the expected downward push on the other leg. Therefore, the absence of downward pressure on the opposite leg when attempting to lift indicates non-physiologic or feigned weakness, making that finding the best way to differentiate malingering.