Elbow MCL Sprain

Procedure

Stand to the side of the patient with their shoulder abducted to 90° and the elbow fully flexed. Apply and hold a constant valgus (abduction) stress at the elbow, then quickly straighten the elbow from full flexion towards extension while maintaining that stress.

Positive Finding

Medial elbow pain that reproduces the patient's symptoms, greatest between roughly 120° and 70° of flexion as the elbow is extended.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

The best-evidenced test for detecting a medial ulnar collateral ligament injury. It picks up 98% of injuries but correctly clears only 75% of people without one (PMID 42087694), which makes it strongest as a rule-OUT test: a negative result is genuinely reassuring, a positive one needs corroborating. Unlike the static valgus tests it stresses the ligament through a range of flexion rather than at one angle, which is likely why it detects more. These figures come from 84 athletes, three-quarters of them baseball players, who all went on to elbow surgery and were examined by specialist surgeons. Surgical findings confirmed the diagnosis, which makes the numbers reliable for that group. Expect weaker performance in a general clinic, where far fewer patients with medial elbow pain will actually have a ligament injury.

Procedure

Stand behind or beside the patient with their shoulder abducted and externally rotated and the elbow flexed to about 90°. Grasp the patient's thumb and pull on it, levering the forearm into further external rotation and creating a valgus stress across the medial elbow.

Positive Finding

Pain along the medial elbow, or a sense of the joint opening, reproducing the patient's symptoms.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

This is now the best-evidenced medial elbow test. In 84 athletes whose diagnosis was confirmed at surgery it detected 77% of ligament injuries and correctly cleared 85% of those without one (PMID 42087694) — better at ruling an injury IN than out. Note the study population were mostly young baseball players heading for surgery, so expect weaker performance in a general clinic.

Procedure

Patient seated with the elbow flexed to 15-30°. Grasp the wrist with one hand and place the other over the lateral elbow, then apply a steady valgus force. Repeat at both 15° and 30° of flexion.

Positive Finding

Pain or laxity felt on the medial side of the elbow under valgus stress.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

A single-position valgus test. It detects 66% of ligament injuries and correctly clears 85% of those without one (PMID 42087694) — the opposite balance to the moving valgus stress test, so a positive result here carries more weight than a negative one. Held at 15-30° of flexion because at full extension the olecranon locks into its fossa and can mask laxity. These figures come from 84 athletes, three-quarters of them baseball players, who all went on to elbow surgery and were examined by specialist surgeons. Surgical findings confirmed the diagnosis, which makes the numbers reliable for that group. Expect weaker performance in a general clinic, where far fewer patients with medial elbow pain will actually have a ligament injury.

Procedure

As for the static valgus stress test, but with the arm positioned in shoulder abduction and external rotation to mimic the late cocking phase of throwing.

Positive Finding

Medial elbow pain or laxity with valgus stress in the throwing position.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

Designed to reproduce the arm position in which throwers actually injure the ligament. In practice it performed no better than the standard static test — 72% sensitivity and 70% specificity (PMID 42087694) — and the study authors noted that changing the arm position without changing the static nature of the test did not improve detection. These figures come from 84 athletes, three-quarters of them baseball players, who all went on to elbow surgery and were examined by specialist surgeons. Surgical findings confirmed the diagnosis, which makes the numbers reliable for that group. Expect weaker performance in a general clinic, where far fewer patients with medial elbow pain will actually have a ligament injury.

Procedure

Place one hand on the elbow to stabilise it and take the patient’s hand as though shaking it. With the forearm held neutral, attempt to supinate the forearm while the patient resists by actively pronating. Maintain the resistance while extending the elbow.

Positive Finding

Reproduction of medial elbow pain or discomfort.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

This test misses roughly five injuries in every six. Sensitivity is 16% and specificity 90%, but its positive likelihood ratio of only 1.5 means a positive result barely shifts the odds (PMID 42087694). It was originally described for pronator teres syndrome and adapted here; it loads the flexor-pronator muscles rather than stressing the ligament, which likely explains the poor detection. Published here because knowing a test does not work is useful.

Procedure

The patient places the fingertips of the affected arm against their own temple or cheek, then presses inward against their head.

Positive Finding

Reproduction of medial elbow pain or discomfort.

Sensitivity / Specificity

Reference: Sciascia AD, Bowman EN, Camp C, et al. Clinical utility of the moving valgus stress test and milking maneuver for medial ulnar collateral ligament injuries of the elbow. Am J Sports Med. 2026;54(8):1993-2002.

Interpretation

The weakest test in the group: it detects only 9% of ligament injuries (PMID 42087694). Its specificity of 95% looks impressive, but a test that almost never fires tells you very little when it does — the positive likelihood ratio is just 1.88. This is a useful illustration that high specificity alone does not make a test worth doing.

Procedure

Patient seated with elbow flexed to 90°. Palpate along the line between the medial epicondyle and the medial coronoid process of the ulna; identify the anterior bundle of the MCL.

Positive Finding

Focal tenderness, swelling, or reproduction of pain directly over the MCL insertion points (epicondyle or coronoid).

Interpretation

Non-specific but valuable in conjunction with other tests to localize structural damage and assess severity; guides imaging decisions and treatment planning. No published study reports the sensitivity or specificity of this test.

Procedure

Patient prone with elbow flexed 90° hanging off table edge. Apply a gentle manual pronation force to the forearm or ask patient to actively pronate against resistance.

Positive Finding

Medial-sided elbow pain or pain at the proximal attachment of the pronator teres and flexor-pronator mass.

Interpretation

Helps differentiate flexor-pronator strain (often coexistent with MCL injury) from isolated MCL ligament injury; useful for treatment targeting. No published study reports the sensitivity or specificity of this test.

Procedure

High-frequency linear ultrasound probe placed longitudinally over the MCL; perform valgus stress dynamically or apply manual valgus load while scanning. Measure gapping of the medial joint space.

Positive Finding

Medial joint-line opening (>2–3 mm compared to contralateral side), ligament discontinuity, hypoechoic edema within the ligament, or non-visualisation of the ligament.

Interpretation

An imaging investigation rather than a physical examination test. Dynamic ultrasound can show the ligament and measure how far the joint opens under stress, and is used in sports medicine where the operator is experienced. It is highly operator-dependent, and the accuracy figures previously shown here could not be traced to any published study.

Procedure

Patient supine with the elbow at or near full extension. Stabilise the distal humerus and apply a valgus force to the forearm.

Positive Finding

Medial joint line opening or reproduction of instability symptoms with the elbow straight.

Interpretation

At full extension the olecranon locks into its fossa and the bones themselves resist the joint opening. That is why the standard valgus stress test is performed at 20-30° of flexion instead. Because of that bony block, a normal result here means very little. Opening that IS felt in full extension suggests instability beyond the ulnar collateral ligament alone and warrants imaging. This manoeuvre is sometimes called a "Lachman-like" test, which is a borrowed knee term rather than a recognised elbow test name. No accuracy study exists.