Holsman Physical Therapy & Wellness P.C.
Clinician Reference
Holsman Physical Therapy & Wellness · Clinics across North Jersey, the Bronx & Brooklyn + in-home therapy
holsmanwellness.com · 1-855-465-7626
📍 724 Ridge Road, Lyndhurst, NJ 📞 1-855-465-7626 ⏰ Mon–Fri: 8 AM – 6 PM
Facebook Instagram X/Twitter
Home› Physical Therapy› Free Self-Checks› Special Tests› Elbow

Elbow Special Tests

Fracture screening, ligament, tendon and nerve tests for the elbow, with what the research says about each.

Reviewed by Dr. Richard Holsman, PT, DPT, NCS · Last reviewed November 13, 2026 · For clinician education

⚠️ For clinicians

For clinician education; special tests support but do not replace a full examination. This page is a reference for physical therapists, occupational therapists, athletic trainers, students and other clinicians. Patients with joint or spine pain should be examined by a licensed clinician.

Several elbow tests come from small single-surgeon or emergency-department studies. The elbow extension test is the best supported for ruling out a fracture after injury.

On this page

Accuracy at a glance

TestTarget conditionSnSp+LR−LRSource
Elbow extension testElbow fracture (adults and children, 1,740 patients)96.8%48.5%—0.03 (adults), 0.11 (children)[1]
Moving valgus stress testMedial collateral ligament insufficiency (21 surgical patients)100%75%——[2]
Hook testComplete distal biceps avulsion (45 surgical patients)100%100%——[3]
Cubital tunnel provocation: elbow flexion, pressure and Tinel’sCubital tunnel syndrome, Tinel’s sign (+ more below)70%———[4]
Cozen’s testAccuracy data not verified—
Mill’s testAccuracy data not verified—

Sn = sensitivity, Sp = specificity, LR = likelihood ratio. A dash means the source we checked did not report that value.

How to read the accuracy numbers

  • Sensitivity: of people who have the condition, the share with a positive test. A highly sensitive test that is negative helps rule the condition out.
  • Specificity: of people without the condition, the share with a negative test. A highly specific test that is positive helps rule it in.
  • Positive likelihood ratio (+LR): how much a positive result raises the odds. About 5–10 is a moderate shift; above 10 is large.
  • Negative likelihood ratio (−LR): how much a negative result lowers the odds. About 0.1–0.2 is a moderate-to-large shift; near 1 means little change.
  • Values depend on the study’s patients, examiners and reference standard. Many studies are small, so treat single-study numbers with caution.

Elbow special tests, step by step

Each test is described in our own words. Compare with the uninvolved side and stop if the test provokes severe pain.

Elbow extension test

Purpose
Screens for fracture after an acute elbow injury.
Patient position
Sitting or supine, arm supported.
How to perform[5]
  1. Ask the patient to lift the arm forward and fully straighten both elbows with the palms up (supinated).
  2. Compare the injured side with the other side.
Positive finding
Positive (test failed): the injured elbow cannot straighten fully. A negative test means full extension, matching the other side.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Elbow fracture (adults and children, 1,740 patients)[1]96.8%48.5%—0.03 (adults), 0.11 (children)
Patients who could fully extend still need follow-up if pain persists; 17 of 602 had a fracture.

Moving valgus stress test

Purpose
Tests the ulnar (medial) collateral ligament, mainly in overhead athletes.
Patient position
Sitting or standing, shoulder abducted to about 90° and turned outward.
How to perform[5]
  1. Fully bend the elbow.
  2. Apply and hold a steady valgus (outward) force at the elbow.
  3. Quickly straighten the elbow while keeping the force on.
Positive finding
Familiar medial elbow pain over the ligament, worst between about 120° and 70° of flexion.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Medial collateral ligament insufficiency (21 surgical patients)[2]100%75%——
Specificity based on only 4 patients without the condition.

Hook test

Purpose
Checks for a complete distal biceps tendon avulsion.
Patient position
Sitting, shoulder slightly abducted, elbow bent to 90°, forearm turned palm up.
How to perform[5]
  1. Ask the patient to actively supinate against light resistance.
  2. From the lateral side, try to hook your index finger under the biceps tendon at the front of the elbow.
Positive finding
Abnormal (positive): no cord-like tendon to hook under.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Complete distal biceps avulsion (45 surgical patients)[3]100%100%——
Single surgeon; the test was intact (though often painful) in partial tears.

Cubital tunnel provocation: elbow flexion, pressure and Tinel’s

Purpose
Provokes ulnar nerve symptoms at the elbow (cubital tunnel syndrome).
Patient position
Sitting.
How to perform[5]
  1. Tinel’s: tap over the ulnar nerve behind the medial epicondyle.
  2. Elbow flexion: fully bend the elbow with the wrist straight and hold.
  3. Pressure-flexion: add finger pressure over the ulnar nerve just proximal to the cubital tunnel while the elbow is fully bent; hold up to 60 seconds.
Positive finding
Tingling or numbness in the ring and little fingers.

Diagnostic accuracy

Target condition (source)SensitivitySpecificity+LR−LR
Cubital tunnel syndrome, Tinel’s sign[4]70%———
Specificity not reported as a number; tests were rarely positive in 33 controls.
Cubital tunnel syndrome, elbow flexion at 30 s[4]32%———
Cubital tunnel syndrome, pressure-flexion at 30 s[4]91%———
Most sensitive of the four tests in this study.

Cozen’s test

Also called: Resisted wrist extension test

Purpose
Provokes lateral elbow tendinopathy (tennis elbow) by loading the wrist extensors.
Patient position
Sitting, elbow bent about 90°, forearm turned down, fist made.
How to perform[5]
  1. Steady the elbow with a thumb over the lateral epicondyle.
  2. Ask the patient to extend the wrist (and turn it slightly toward the thumb side) against your resistance.
Positive finding
Familiar pain at the lateral epicondyle.

Diagnostic accuracy

Accuracy data not verified. We did not find a diagnostic accuracy study for this test that we could check, so we show no numbers.

Mill’s test

Purpose
Stretches the wrist extensor origin to provoke lateral elbow pain.
Patient position
Sitting or standing.
How to perform[5]
  1. With a finger on the lateral epicondyle, passively turn the forearm down, flex the wrist fully and straighten the elbow.
Positive finding
Familiar pain at the lateral epicondyle.

Diagnostic accuracy

Accuracy data not verified. We did not find a diagnostic accuracy study for this test that we could check, so we show no numbers.

What we left out

Varus/valgus stress at 20–30°, milking maneuver and the elbow “Tinel’s” specificity are not shown with numbers. No accuracy study for Cozen’s or Mill’s test was verified. We only show accuracy numbers we could check against the original study or review.

Sources, review and disclosures

Graded citations

How we grade sources. A = systematic review or meta-analysis. B = single prospective diagnostic accuracy study. C = small, retrospective or case-control study, or a clinical prediction rule that has only been derived (not yet validated). D = expert clinical opinion (our test descriptions). Every accuracy number on this page was checked against the cited abstract or full text on November 13, 2026. If we could not check a number, we left it out and say “accuracy data not verified.”

  1. Grade B Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ. 2008;337:a2428. doi:10.1136/bmj.a2428 (abstract; full text free at PMC2600962). PubMed 19066257
  2. Grade C O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress test” for medial collateral ligament tears of the elbow. Am J Sports Med. 2005;33(2):231-239. doi:10.1177/0363546504267804 (abstract; 21 surgical patients). PubMed 15701609
  3. Grade B O’Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007;35(11):1865-1869. doi:10.1177/0363546507305016 (abstract). PubMed 17687121
  4. Grade C Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994;19(5):817-820. doi:10.1016/0363-5023(94)90193-7 (abstract). PubMed 7806810
  5. Grade D Holsman Physical Therapy clinical guidance. Patient position, test steps and positive findings written in our own words by Holsman physical therapists and reviewed by Dr. Richard Holsman, PT, DPT, NCS. Expert opinion, not a research source.

Reviewer

Reviewed by Dr. Richard Holsman, PT, DPT, NCS (Board-Certified Clinical Specialist in Neurologic Physical Therapy), founder of Holsman Physical Therapy. Last reviewed: November 13, 2026.

Change log

  • November 13, 2026: Page published. Test descriptions written in our own words; accuracy values checked against the cited sources.

Review policy

We re-check every number on this page against its source at least once a year, and sooner if a source is updated, a better study is published or a reader reports a problem. Changes are listed in the change log with the date. To report an error, contact us.

Licensing

Test descriptions, steps and the accuracy summaries are original text by Holsman Physical Therapy. Accuracy values are individual numbers cited with credit to the original studies; no tables, figures or text from journals, textbooks or other websites are reproduced. Linking to a source does not imply its endorsement. Demonstration videos, when added, will be filmed by Holsman physical therapists with consenting adult models.

Conflict of interest and advertising

This page is published by Holsman Physical Therapy and Wellness, P.C., which runs outpatient and in-home therapy practices; that is our only commercial interest. The page carries no advertising, no sponsorship and no affiliate links, and we received no payment from any source for it. Holsman Physical Therapy is not affiliated with the authors or publishers cited, and they do not endorse this website.

For clinician education; special tests support but do not replace a full examination. A positive or negative test changes the probability of a condition; it does not make a diagnosis. Interpret every result with the history, the rest of the examination, imaging when indicated, and clinical judgment. Stop any test that provokes severe pain or neurological symptoms.

Common Questions

Can the elbow extension test rule out a fracture?

It helps. In a study of 1,740 emergency patients, the negative likelihood ratio for full elbow extension was 0.03 in adults and 0.11 in children, but 17 of the 602 patients who could fully extend still had a fracture, so follow-up matters if pain continues.

What does the hook test check?

Whether the distal biceps tendon is completely torn. If you cannot hook a finger under the tendon from the lateral side while the patient supinates, the tendon is likely avulsed. In a 45-patient surgical study it was 100% sensitive and specific.

Referring a Patient?

Holsman physical therapists see patients at clinics across North Jersey, the Bronx and Brooklyn, plus in-home visits.

📞 Call 1-855-465-7626
Printed from holsmanwellness.com/tools/orthopedic-special-tests/elbow/ · Holsman Physical Therapy & Wellness · Call 1-855-465-7626 to schedule physical therapy · Clinician reference, not a diagnosis.