Physical Exams Positive in Lateral Epicondylitis
The most reliable physical exams for diagnosing lateral epicondylitis include Cozen's test, Mill's test, and Maudsley's test, which all demonstrate high sensitivity and specificity when performed correctly. 1
Key Physical Examination Tests
Cozen's Test: This test has the highest sensitivity (96.7%) among traditional tests for lateral epicondylitis. It involves resisted wrist extension while the examiner stabilizes the elbow, which reproduces pain at the lateral epicondyle 1
Mill's Test: With a sensitivity of 86.7%, this test involves passively pronating the forearm while extending the wrist and elbow, which stretches the common extensor tendon and reproduces pain at the lateral epicondyle 1
Maudsley's Test: This test has a sensitivity of 83.3% and involves resisted extension of the middle finger while the elbow is extended, specifically targeting the extensor digitorum muscle 1
The "Selfie Test": A newer diagnostic test with high sensitivity (93.3%) where the patient attempts to take a selfie-like position with the affected arm, which reproduces pain at the lateral epicondyle due to the specific positioning of wrist extension and forearm supination 1
Diagnostic Accuracy
The combination of multiple positive tests increases diagnostic confidence, with the highest accuracy achieved when both Cozen's and the Selfie test are positive (sensitivity >93%) 1
Physical examination findings should be correlated with the patient's history of repetitive wrist extension activities, which is particularly common in housewives (39.33% prevalence) and individuals performing repetitive supination and pronation movements 2
Imaging Correlation
While physical examination remains the primary diagnostic approach, MRI shows high inter- and intraobserver reliability for confirming epicondylalgia with 90-100% sensitivity and 83% specificity 3
Ultrasound examination can complement physical findings, showing moderate agreement with MRI for diagnosing common extensor tendon tears (sensitivity 64.25%, specificity 85.19%) 3
Advanced ultrasound techniques like sonoelastography and superb microvascular imaging have improved diagnostic accuracy (sensitivity 94%, specificity 98%) 3
Common Pitfalls and Considerations
Pain may be referred from cervical spine pathology or radial tunnel syndrome, so negative provocative tests with persistent symptoms should prompt investigation of other causes 3
Bilateral symptoms are less common (11.86% of cases) and may indicate systemic inflammatory conditions rather than typical overuse tendinopathy 2
The right arm is more commonly affected (71.19% of cases) than the left (16.95%), likely due to hand dominance patterns 2
Chronic cases (59.32%) may show less dramatic responses to provocative testing than acute cases (40.67%) due to tissue adaptation and modified pain responses 2
By systematically applying these physical examination techniques, clinicians can accurately diagnose lateral epicondylitis and distinguish it from other causes of lateral elbow pain.