The Balance Error Scoring System (BESS) is an easy-to-use static balance test. It is commonly used in groups of athletes with concussions or mild traumatic brain injuries. Information gained from this clinical balance tool can be used to help clinicians get back into the game Decision after minor head injury.
BESS can be executed in almost any environment and takes about 10 minutes to execute.
May be used by people with balance and postural stability issues such as functional ankle instability and those with disorders affecting the vestibular system and/or brain. Examples include sports-related concussion, stroke, Parkinson’s disease, multiple sclerosis, traumatic brain injury, blast exposure army. Blunt trauma to the head can cause persistent dizziness and balance problems. 
- Foam pad
- An assistant to act as a spotter
- BESS test protocol (instructions to read during the test)
- BESS score card
The balance test consists of three poses on two different surfaces. The three stances are two-leg stance, one-leg stance, and tandem stance. Two different surfaces include a solid (ground) and a foam surface.
Athletes stand with hands on hips and eyes closed, maintaining a consistent foot position according to posture. Shoes should not be worn.
- In a two-legged stance, place your feet flat on the test surface, about the width of your pelvis.
- In the single-leg stance, the athlete stands on the non-dominant leg with the opposite limb held in approximately 20° of hip flexion, 45° of knee flexion, and a neutral position on the frontal plane.
- In a tandem stand, one foot is placed in front of the other, with the heel of the front foot touching the toes of the rear foot. The athlete’s non-dominant leg is in the rear position. Leg dominance should be determined by the athlete’s kick preference .
The trial time is 20 seconds. Calculate the wrong amount from the right standpoint. The inspector should start counting errors only after the individual has taken the correct test position. If multiple errors occur simultaneously, only one error is counted. The maximum number of errors for a single condition is 10. 0-60 points (lower scores indicate better balance and fewer errors). The errors from each trial are added together to obtain a total score (out of 60 points).
- Mistakes included removing hands from the iliac crest, opening eyes, tripping or falling, abducting or hip flexion beyond 30 degrees, lifting the front foot or heel off the test surface, and leaving the correct test position for more than 5 seconds.
- Read the subject instructions written in the testing protocol.
This 6-minute video demonstrates the performance of the BESS.
BESS normative reference values stratified by age.
Age N Mean Median SD Superior Above Average About Normal Below Average Poor Very Difference 20-296511.311.04.80-56-78-1415-1718-2324+30-3917311.511.05.50-45-78-1516-1819-2627+40-4935212.511.56.20-56-89-1657-2022-404.272 67-89–1819–2425–3334+55–5919716.515.07.60–78–1011–2021–2829–3536+60–6414818.016.57.80–89–1213–2223–28279+198.519–401–101–7–1207.2 3233–3839+
BESS is a balanced clinical assessment with generally moderate to good reliability. BESS correlates with laboratory-based criteria-related validity measures and is construct-valid. Score functional ankle instability with concussion increases lateral ankle support fatigue and age. After completing a comprehensive neuromuscular training program, scores should improve. 
- Iverson GL, Koehle MS. Normative data for the balance error scoring system in adults. Rehabilitation research and practice. 2013 Jan 1;2013. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3614029/ (accessed 28.5.2022)
- My sports clinic BESS Available: https://mysportclinic.org/concussion-clinic/concussion-testing/balance-error-scoring-system-bess/ (accessed 28.5.2022)
- Duke Neurology. Sports Concussion Exam (3 of 9): Balanced Error Scoring System (BESS). Available from: https://www.youtube.com/watch?v=fA392PbM3-A
- Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports health. 2011 May;3(3):287-95. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445164/ (accessed 28.5.2022)