Mill’s Test

Mill’s Test is a clinical orthopedic examination used to diagnose lateral epicondylitis (tennis elbow), a condition characterized by pain at the lateral epicondyle of the humerus and reduced grip strength. It is one of several provocation tests employed to confirm the diagnosis and to differentiate it from other elbow pathologies.

Clinical Presentation

Lateral epicondylitis affects both men and women equally, with a lifetime prevalence of 1–3%, most commonly between the ages of 35–50 years【1】【2】.

Common Symptoms

• Pain localized to the lateral elbow, sometimes radiating down the forearm

• Weak grip strength, especially during lifting

• Point tenderness at the lateral epicondyle and the tendon origin of extensor carpi radialis brevis (ECRB)【3】【4】

Condition	Age	Mechanism	Aggravated by	Observation	Tenderness Location
Lateral epicondylitis	35–55 yrs	Gradual overuse	Wrist extension and gripping	Possible swelling at elbow	Over ECRB tendon origin

Pathophysiology

• Lateral epicondylitis involves degenerative changes in the ECRB tendon, often related to hypovascular zones, eccentric and concentric loading, and microtears【5】.

• The ECRL tendon is also affected in approximately 35% of cases【6】.

• Histological findings include micro-avulsion fractures, lymphocytic infiltration, calcification, and fibrinoid degeneration【7】【8】.

Test Procedure

Patient Position

• Patient seated with the elbow fully extended.

Examiner’s Action

• One hand palpates the lateral epicondyle.

• The examiner pronates the forearm and fully flexes the wrist while keeping the elbow extended【8】.

Interpretation

• Positive Test: Pain at the ECRB origin on the lateral epicondyle → indicates tennis elbow.

• Negative Test: No pain elicited during maneuver.

Diagnostic Validity and Evidence

Parameter	Value
Sensitivity	53%
Specificity	100%
Positive Likelihood Ratio	∞ (perfect rule-in)
Negative Likelihood Ratio	0.47

• Pienimäki et al. (2002): Strong association between lateral elbow pain and a positive Mill’s Test, supporting clinical validity【11】.

• Wadsworth: Reported that a forceful Mill’s maneuver under anesthesia could produce an audible “crack” with subsequent symptom relief, though without scientific explanation【9】.

• Despite its long-standing use, expert consensus ranks Mill’s Test at Level 5 evidence, limiting the strength of recommendations【10】.

Alternative Tests for Lateral Epicondylitis

• Maudsley’s Test – resisted extension of the third finger.

• Cozen’s Test – resisted wrist extension with radial deviation in pronation.

• Chair Lift Test – lifting a chair with a three-finger grip and extended elbow.

Conclusion

Mill’s Test is a simple and highly specific clinical tool for diagnosing lateral epicondylitis. While its sensitivity is limited, a positive result strongly confirms the diagnosis due to perfect specificity. For best diagnostic accuracy, Mill’s Test should be performed alongside other provocation tests and supported with imaging when needed.

Sources

1. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clinics in sports medicine. 2003 Oct 1;22(4):813-36.

2. Allander E. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scandinavian journal of rheumatology. 1974 Jan 1;3(3):145-53.

3. Whaley AL, Baker CL. Lateral epicondylitis. Clinics in sports medicine. 2004 Oct 1;23(4):677-91.

4. Pomerance J. Radiographic analysis of lateral epicondylitis. Journal of shoulder and elbow surgery. 2002 Mar 1;11(2):156-7.

5. Faro F, Wolf JM. Lateral epicondylitis: review and current concepts. The Journal of hand surgery. 2007 Oct 1;32(8):1271-9.

6. Pecina M. Bojanic. Overuse injuries of the musculoskeletal system. CRC press Boca Rotan, USA, 1993

7. Wadsworth TG. Tennis elbow: conservative, surgical, and manipulative treatment. British medical Journal (Clinical research ed.). 1987 Mar 3;294(6572):621.

8. Geoffroy P, Yaffe MJ, Rohan I. Diagnosing and treating lateral epicondylitis. Canadian Family Physician. 1994 Jan;40:73.

9. Clinical Examination Videos. Tennis elbow test - Mills test. Available from: https://www.youtube.com/watch?v=gBReeVQqmpc [Accessed 9 November 2020]

10. Saroja G, Aseer PA, Venkata Sai PM. Diagnostic accuracy of provocative tests in lateral epicondylitis. Int J Physiother Res. 2014 Dec 11;2(6):815-23.

11. Pienimäki T, Tarvainen T, Siira P, Malmivaara A, Vanharanta H. Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow. The Clinical journal of pain. 2002 May 1;18(3):164-70.

12. Mills GP. The treatment of “tennis elbow.”. British Medical Journal. 1928 Jan 1;1(3496):12.

13. Mills GP. Treatment of tennis elbow. British Medical Journal. 1937 Jul 7;2(3995):212.