Handgrip Strength
Handgrip strength (HGS) measures maximal voluntary grip force. It is a practical assessment of muscle strength and a useful prompt to investigate frailty, sarcopenia or impaired recovery. It complements the preoperative assessment.[1][2][3]
Measurement
Use a calibrated dynamometer and a reproducible protocol with appropriate reference data. Record device, handle setting, posture, tested hand, number of attempts and whether the result is a maximum or mean. A common hydraulic-dynamometer protocol uses a seated patient, neutral shoulder and forearm and elbow flexed to 90°; protocols differ, so comparisons require matching methods.[4][1]
AWGS 2025 recommends two to three attempts in both hands and the maximum value, with positioning appropriate to the mechanical spring or hydraulic device. Allow recovery between efforts and consistent encouragement. Pain, arthritis, focal nerve injury, stroke, cognition and inability to follow instructions can limit validity. Consider a suitable lower-limb strength assessment when the hands cannot be tested.[2][1]
In 497 patients with cancer, protocol choice changed measured values, and the difference was potentially clinically meaningful in over 60% of men and 40% of women. The classification of weakness was not significantly affected. This supports standardizing the protocol.[5]
Reference Thresholds
| Framework and population | Low HGS in men | Low HGS in women | How it is used |
|---|---|---|---|
| EWGSOP2, principally older European populations | <27 kg | <16 kg | Low strength supports probable sarcopenia; assess muscle quantity/quality for confirmation |
| AWGS 2025, Asian adults ≥65 years | <28 kg | <18 kg | Diagnosis requires concurrent low muscle mass |
| AWGS 2025, Asian adults 50–64 years | <34 kg | <20 kg | New age-specific threshold; assess muscle mass with the corresponding criteria |
These are framework-specific thresholds, not universal normal ranges or surgical cancellation criteria. AWGS 2025 retains the older-adult grip thresholds but changes the diagnostic framework and adds middle-aged adults.[1][2]
Age, body size, sex, geography and measurement method affect reference values. A 2025 systematic review provides sex- and age-specific percentiles from 2.4 million adults in 69 countries and regions; these norms contextualize a result but do not set a surgical cutoff.[25] For example, pooled data from 12 British studies with 49,964 participants showed peak median HGS of 51 kg in men aged 29–39 and 31 kg in women aged 26–42.[6] Grip strength falls progressively with age. In the Jerusalem Longitudinal Cohort, mean HGS declined between ages 70 and 90 from 35.3 to 19.5 kg in men and from 21.3 to 11.5 kg in women.[7]
Sarcopenia Assessment
EWGSOP2 (Find, Assess, Confirm, Severity). Find cases through SARC-F or clinical suspicion; assess strength with grip or chair stands; confirm with low muscle quantity or quality; assess severity using physical performance. A low SARC-F score does not reliably exclude sarcopenia when symptoms or examination raise concern.[1]
AWGS 2025. Low strength and low muscle mass establish sarcopenia. Physical performance remains clinically valuable but is treated as an outcome; the previous separate severe-sarcopenia category was removed. Age-specific DXA or BIA thresholds and further detail are in the original consensus. Do not mix thresholds or diagnosis stages from different frameworks.[2]
For malnutrition, the GLIM 2025 update explicitly states that muscle strength cannot substitute for muscle mass. HGS is functional information. Use weight loss, BMI or an appropriate muscle-mass assessment to establish a GLIM phenotype, together with an etiologic criterion.[8]
What the Outcome Evidence Shows
| Evidence | Finding | Clinical interpretation |
|---|---|---|
| UK Biobank, 502,293 participants | Each 5 kg lower HGS associated with higher all-cause mortality: HR 1.16 in men and 1.20 in women[9] | Population association |
| GI tumor surgery meta-analysis, 8 observational studies / 2,291 patients | Low HGS associated with complications OR 2.23 (1.43–3.50), pneumonia OR 5.16 (3.17–8.38), ileus OR 2.48 (1.09–5.65), short-term mortality OR 7.28 (1.90–27.92)[10] | Heterogeneous definitions and wide mortality interval; these are not validated risk multipliers for GU reconstruction |
| Choi cohort, 648 patients aged ≥65 referred for geriatric assessment before elective general surgery | Multidimensional frailty score discriminated the postoperative-complication composite better than HGS (C-index 0.750 vs 0.566); HGS did not significantly improve age- or ASA-based prediction | A single strength measurement should not replace comprehensive assessment |
| 2026 abdominal-surgery cohort, 223 patients | Higher preoperative HGS associated with shorter stay; acute perioperative HGS changes were not associated with outcomes | Supports baseline functional assessment, without validating a postoperative grip target |
Sources: UK Biobank,[9] GI surgery review,[10] Choi,[3] and Montanari.[11] In Choi's fully adjusted analyses, only the multidimensional frailty score predicted six-month mortality, supporting comprehensive assessment without establishing grip-strength superiority. The frailty score's discrimination was measured as a C-index (0.750, compared with 0.566 for grip strength).
Population Cohorts, Function and Disability
In PURE (139,691 participants aged 35 to 70 in 17 countries; median follow-up 4.0 years), each 5 kg lower grip strength was associated with higher all-cause mortality (HR 1.16, 95% CI 1.13–1.20) and cardiovascular mortality (HR 1.17, 1.11–1.24).[12] Grip strength predicted all-cause and cardiovascular mortality more strongly than systolic blood pressure.[12] In UK Biobank, each 5 kg lower grip strength was also associated with cardiovascular mortality (HR 1.19 in women, 1.22 in men) and cancer mortality (HR 1.17 in women, 1.10 in men; colorectal, lung and breast cancer, but not prostate cancer).[9] Adding grip strength to an office-based risk score increased the C-index by 0.013 for all-cause mortality.[9] Marginal structural models in 121,116 adults aged 50 years or older in the SHARE survey associated a 5 kg increase in grip strength with lower all-cause mortality (HR 0.86) and cardiovascular mortality (HR 0.86).[13]
Low grip strength is also associated with loss of independence. In 17,747 older US adults, each 5 kg decrease was associated with higher odds of limitation in eating (20%), walking (14%), bathing (14%), dressing (9%), transferring (8%) and toileting (6%).[14] In the Jerusalem cohort, lowest-quartile grip strength predicted later dependence in activities of daily living from age 78 to 85 (OR 2.68, 95% CI 1.04–6.89) and from 85 to 90 (OR 2.31, 1.01–5.30) after adjustment for education, self-rated health, physical activity, diabetes, depression and cognition.[7] In 1,765 older Japanese adults, grip strength showed an inverse dose-response relationship with disability that was independent of body composition. Mortality in men depended more on muscle mass.[15]
Nutritional Status and Kidney Disease
Muscle function reacts early to nutritional deprivation, and HGS is used as a marker of nutritional status and as an outcome in nutrition trials.[16] In one hospital cohort of 490 patients (mean age 69.5 years), the HGS cutoff for severe GLIM malnutrition was 20 kg in men younger than 70 (AUC 0.82) and 11 kg in women older than 70 (AUC 0.78). These are single-institution values, not validated thresholds.[17]
Low HGS is more common in chronic kidney disease. In a Korean national survey, low HGS was present in 25.2% of participants with CKD and 6.2% of those without, and CKD was independently associated with low HGS (OR 1.91 in men, 1.57 in women).[18] Among 789 community-dwelling older men with baseline eGFR >30 mL/min/1.73 m², stage G3 impairment (eGFR <60) was associated with faster five-year grip-strength decline; appendicular lean mass adjusted for BMI declined across the cohort without a significant eGFR-category effect.[19] In a small study enrolling 75 participants, the analysis tables included 74 (control 16, CKD 17, ESRD 41); low grip strength occurred in 17/41 (41.5%) of the ESRD subgroup.[20] Across all three groups, low grip strength was associated with hospitalization during 600 days of follow-up. Serum indoxyl sulfate was associated with low grip strength (adjusted OR 8.5, 95% CI 1.8–40.2).[20]
Exercise, Nutrition and Follow-up
Resistance exercise, often combined with balance or aerobic training and individualized nutrition, is central to sarcopenia management. Tailor the program to medical stability, baseline ability and rehabilitation goals.[2]
A meta-analysis of 24 trials in 3,018 healthy community-dwelling older adults found small effects of exercise training on grip strength (SMD 0.28, 95% CI 0.13–0.44), with task-specific and multimodal training giving the largest transfer.[21] In older adults with sarcopenia, a Bayesian analysis of 13 studies (711 participants) estimated separate optima for frequency (3 sessions per week), intensity (49% of one-repetition maximum), duration (19 weeks) and volume (1,400 repetitions per week). The roughly 7–8 kg grip-strength differences are modeled estimates for individual dose dimensions, not the measured effect of one combined or perioperative program.[22] The effective ranges were wide (2–5 sessions per week, 30–75% of one-repetition maximum, 4–24 weeks).[22]
In a network meta-analysis of 42 RCTs involving 3,728 older adults with sarcopenia, the resistance-plus-balance-plus-nutrition estimate—supported directly by one 64-person RCT—was 4.19 kg greater HGS than usual care (95% CI 2.55–5.83; moderate certainty).[23] The point estimate was below the review's 5 kg minimally important difference, although the interval crossed it. This was not a 4.19 kg incremental benefit over exercise alone. Quality-of-life and functional effects differed by intervention; mortality evidence was sparse.[23] In SPRINTT’s prespecified primary analysis of 1,205 older adults with physical frailty and sarcopenia (SPPB 3–7), multicomponent activity and nutrition counseling reduced mobility disability (inability to walk 400 m in 15 minutes; 283/605 vs 316/600; HR 0.78, 95% CI 0.67–0.92) but recorded more falls than lifestyle education (80/605 vs 49/600; RR 1.62, 95% CI 1.16–2.27) during up to 36 months of follow-up.[29] In a cluster randomized trial of 245 community-dwelling older adults already attending weekly group exercise, adding home-based exercise with protein counseling did not change the primary physical-performance outcome. Muscle strength improved by 2.32 kg at 6 months and remained improved at 12 months compared with control.[24]
Use repeat measurements under the same conditions to contribute to follow-up, together with intake, weight, mobility and patient goals. The network-derived doses above are estimates.[22]
Reconstructive Application
Consider HGS when weakness, weight loss, advanced age, chronic disease or a major planned operation raises concern about physiological reserve. A low value can trigger a fuller assessment and dietetic, physiotherapy or geriatric input. Before AUS implantation after prostate treatment, assess pump use separately from HGS and ensure adequate physical and cognitive ability to operate the device (AUA/GURS/SUFU Clinical Principle).[28] In a 39-patient prospective AUS study, pinch strength was associated with satisfaction and nine-hole peg-test performance with confidence at three months; in a 29-patient IPP study, grip strength was associated with less difficulty of use at three months. Neither study validated a cutoff for implantation.[26][27]
Settings where a bedside grip test is a reasonable first step include cystectomy with diversion, complex prolapse or pelvic floor reconstruction, staged gender-affirming surgery, urethroplasty with buccal grafting and repair of radiation-related or post-pelvic-cancer fistula. The surgical outcome data come from gastrointestinal tumor and abdominal operations, and no grip threshold has been validated for these genitourinary settings. Bedside dynamometry needs no laboratory test or imaging and is practical when CT or bioimpedance body composition is unavailable in clinic. Allow time for the chosen protocol’s repeated attempts and rest periods.[5] Operative timing depends on the whole clinical picture, urgency and expected benefit. A grip number alone does not set it.
In CKD, dialysis or recent trauma, interpret current HGS alongside illness effects and functional history. A measurement after injury is not a measurement of preinjury reserve. For hand disability or neurological weakness, select another appropriate test rather than applying population grip cutoffs mechanically.
See Also
References
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2. Chen LK, Hsiao FY, Akishita M, et al. "A focus shift from sarcopenia to muscle health in the Asian Working Group for Sarcopenia 2025 Consensus Update." Nature Aging. 2025;5:2164–2175. doi:10.1038/s43587-025-01004-y.
3. Choi JY, Kim KI, Choi Y, et al. "Comparison of multidimensional frailty score, grip strength, and gait speed in older surgical patients." Journal of Cachexia, Sarcopenia and Muscle. 2020;11(2):432–440. doi:10.1002/jcsm.12509
4. Bohannon RW. "Considerations and Practical Options for Measuring Muscle Strength: A Narrative Review." BioMed Research International. 2019;2019:8194537. doi:10.1155/2019/8194537
5. Chen X, Xie L, Xia X, et al. "Effects of measurement protocols and repetitions on handgrip strength weakness and asymmetry in patients with cancer." Journal of Cachexia, Sarcopenia and Muscle. 2024;15(1):220–230. doi:10.1002/jcsm.13373
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9. Celis-Morales CA, Welsh P, Lyall DM, et al. "Associations of Grip Strength With Cardiovascular, Respiratory, and Cancer Outcomes and All Cause Mortality: Prospective Cohort Study of Half a Million UK Biobank Participants." BMJ. 2018;361:k1651. doi:10.1136/bmj.k1651
10. Jiang X, Xu X, Ding L, et al. "Predictive Value of Preoperative Handgrip Strength on Postoperative Outcomes in Patients With Gastrointestinal Tumors: A Systematic Review and Meta-Analysis." Supportive Care in Cancer. 2022;30(8):6451–6462. doi:10.1007/s00520-022-06983-x
11. Montanari E, Boccardi V, Semeraro E, et al. "From Age to Physiological Reserve: Frailty and Muscle Strength in Early Postoperative Outcomes After Abdominal Surgery." American Journal of Surgery. 2026;258:117014. doi:10.1016/j.amjsurg.2026.117014
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16. Norman K, Stobäus N, Gonzalez MC, Schulzke JD, Pirlich M. "Hand Grip Strength: Outcome Predictor and Marker of Nutritional Status." Clinical Nutrition. 2011;30(2):135–142. doi:10.1016/j.clnu.2010.09.010
17. Matsumoto Y, Iwai K, Namikawa N, et al. "The Relationship Between Existing Nutritional Indicators and GLIM Criteria: A One-Institution Cross-Sectional Analysis." Clinical Nutrition. 2020;39(10):3099–3104. doi:10.1016/j.clnu.2020.01.016
18. Lee YL, Jin H, Lim JY, Lee SY. "Relationship Between Low Handgrip Strength and Chronic Kidney Disease: KNHANES 2014–2017." Journal of Renal Nutrition. 2021;31(1):57–63. doi:10.1053/j.jrn.2020.03.002
19. Toyama T, van den Broek-Best O, Ohkuma T, et al. "Associations of Impaired Renal Function With Declines in Muscle Strength and Muscle Function in Older Men: Findings From the CHAMP Study." The Journals of Gerontology. Series A. 2019;74(11):1812–1820. doi:10.1093/gerona/glz100
20. Hou YC, Liu YM, Liao MT, et al. "Indoxyl Sulfate Mediates Low Handgrip Strength and Is Predictive of High Hospitalization Rates in Patients With End-Stage Renal Disease." Frontiers in Medicine. 2023;10:1023383. doi:10.3389/fmed.2023.1023383
21. Labott BK, Bucht H, Morat M, Morat T, Donath L. "Effects of Exercise Training on Handgrip Strength in Older Adults: A Meta-Analytical Review." Gerontology. 2019;65(6):686–698. doi:10.1159/000501203
22. Hua-Rui L, Shouliang H, Zhengze Y, et al. "Optimal Dose of Resistance Training to Improve Handgrip Strength in Older Adults With Sarcopenia: A Systematic Review and Bayesian Model-Based Network Meta-Analysis." Frontiers in Physiology. 2025;16:1564988. doi:10.3389/fphys.2025.1564988
23. Shen Y, Shi Q, Nong K, et al. "Exercise for sarcopenia in older people: A systematic review and network meta-analysis." Journal of Cachexia, Sarcopenia and Muscle. 2023;14(3):1199–1211. doi:10.1002/jcsm.13225
24. van den Helder J, Mehra S, van Dronkelaar C, et al. "Blended home-based exercise and dietary protein in community-dwelling older adults: a cluster randomized controlled trial." Journal of Cachexia, Sarcopenia and Muscle. 2020;11(6):1590–1602. doi:10.1002/jcsm.12634
25. Tomkinson GR, Lang JJ, Rubín L, et al. "International norms for adult handgrip strength: A systematic review of data on 2.4 million adults aged 20 to 100+ years from 69 countries and regions." J Sport Health Sci. 2025;14:101014. doi:10.1016/j.jshs.2024.101014
26. Campbell K, Vetter J, Vilson FL, et al. "Manual Dexterity Predictors of Artificial Urinary Sphincter Success." Urology. 2024;188:144–149. doi:10.1016/j.urology.2024.04.013
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29. Bernabei R, Landi F, Calvani R, et al. "Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project)." BMJ. 2022;377:e068788. doi:10.1136/bmj-2021-068788