Mill’s Test: Difference between revisions
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== Purpose  ==
== Purpose  ==


Diagnosing Lateral Epicondylitis in the elbow, also known as “Tennis Elbow”.  
Mill's test aids in diagnosing [[Lateral Epicondylitis]] in the elbow, also known as “Tennis Elbow”.  


==== Clinical presentation  ====
=== Clinical presentation  ===


Presenting equally in men and women, 1% to 3% of the population will experience lateral epicondylitis in their lifetime, usually between ages 35 and 50.<ref name="Nirschl RP">Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med 2003;22:813– 836.</ref><ref name="Allander E. et al">Allander E. Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes. Scand J Rheumatol 1974;3:145–153.</ref> Patients report pain at the lateral elbow that radiates down the forearm. In addition, patients often complain of weakened grip and difficulties lifting objects. On physical examination, patients typically have point tenderness medial and distal to the lateral epicondyle.<ref name="Whaley AL, Baker CL">Whaley AL, Baker CL. Lateral epicondylitis. Clin Sports Med 2004;23:677– 691</ref><ref name="Pomerance J. et al">Pomerance J. Radiographic analysis of lateral epicondylitis. J Shoulder Elbow Surg 2002;11:156 –157.</ref>[[Image:Mills test 2.png|frame|right|Mills test 2.png]]
Presenting equally in men and women, 1% to 3% of the population will experience lateral epicondylitis in their lifetime, usually between ages 35 and 50.<ref name="Nirschl RP">Nirschl RP, Ashman ES. [https://www.sportsmed.theclinics.com/article/S0278-5919(03)00051-6/abstract Elbow tendinopathy: tennis elbow.] Clinics in sports medicine. 2003 Oct 1;22(4):813-36.</ref><ref name="Allander E. et al">Allander E. [https://www.tandfonline.com/doi/abs/10.3109/03009747409097141 Prevalence, incidence, and remission rates of some common rheumatic diseases or syndromes]. Scandinavian journal of rheumatology. 1974 Jan 1;3(3):145-53.</ref> Patients report pain at the lateral elbow that radiates down the forearm. Also, patients often complain of a weakened grip and difficulties lifting objects. On physical examination, patients typically have point tenderness medial and distal to the lateral epicondyle.<ref name="Whaley AL, Baker CL">Whaley AL, Baker CL. [https://europepmc.org/article/med/15474229 Lateral epicondylitis]. Clinics in sports medicine. 2004 Oct 1;23(4):677-91.</ref><ref name="Pomerance J. et al">Pomerance J. [https://www.sciencedirect.com/science/article/pii/S105827460290282X Radiographic analysis of lateral epicondylitis]. Journal of shoulder and elbow surgery. 2002 Mar 1;11(2):156-7.</ref>  
 
<br>  


{| cellspacing="1" cellpadding="1" border="1" style="width: 577px; height: 157px"
{| cellspacing="1" cellpadding="1" border="1" style="width: 577px; height: 157px"
|-
|-
| Condition  
| '''Condition'''
| Patient age  
| '''Patient age'''
| Mechanism of injury  
| '''Mechanism of injury'''
| Symptoms aggrevated by  
| '''Symptoms aggravated by'''
| Observation  
| '''Observation'''
| Tenderness with palpation
| '''Tenderness with palpation'''
|-
|-
|  
|  
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| 35-55  
| 35-55  
| Gradual overuse  
| Gradual overuse  
| Activities involving wrist extention/grasping  
| Activities involving wrist extension/grasping  
| Possible swelling (over lateral elbow)  
| Possible swelling (over the lateral elbow)  
| Lateral elbow (over extensor carpi radialis brevis)
| Lateral elbow (over extensor carpi radialis brevis)
|}
|}  


<br>
=== Pathology  ===


==== Pathology  ====
The histological aspects of the injury to the Extensor carpi radialis brevis (ECRB) origin appears to be multifaceted, involving hypovascular zones, eccentric &amp; concentric tendon stresses, and a microscopic degenerative response.<ref name="FARO F et al">Faro F, Wolf JM. [https://www.sciencedirect.com/science/article/pii/S0363502307006491 Lateral epicondylitis: review and current concepts.] The Journal of hand surgery. 2007 Oct 1;32(8):1271-9.</ref><br>In most cases, the lesion involves the specialized junctional tissue (intercellular adhesion molecules) at the origin of the common extensor muscle at the lateral humeral epicondyle, specifically the tendinous origin of the [[Extensor Carpi Radialis Brevis]] (ECRB), and in 35% of the cases, the origin of the Extensor Carpi Radialis Longus (ECRL) will also be overstrained.<ref name="Pecina M. and Bojanic">Pecina M. Bojanic. Overuse injuries of the musculoskeletal system. CRC press Boca Rotan, USA, 1993</ref> The lesion is characterized by microscopic tears, which may be superficial or deep and situated at the tendinous origin of ECRB into the periosteum of the lateral humeral epicondyle. Micro avulsion fractures may be seen as well as lymphocyte infiltration, calcification, scar tissue, and fibrinoid degeneration may be evident in some cases; repair is by immature fibroblasts.<ref name="Wadsworth T et al">Wadsworth TG. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1245660/ Tennis elbow: conservative, surgical, and manipulative treatment]. British medical journal (Clinical research ed.). 1987 Mar 7;294(6572):621.</ref><ref name="Geoffroy P., et al.">Geoffroy P, Yaffe MJ, Rohan I. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379994/ Diagnosing and treating lateral epicondylitis]. Canadian Family Physician. 1994 Jan;40:73.</ref>


The histological aspects of the injury to the ECRB origin appears to be multifaceted, involving hypovascular zones, eccentric &amp; concentric tendon stresses, and a microscopic degenerative response.<u><ref name="FARO F et al">FARO F , Wolf J. Lateral epicondylitis: Review and current concepts- journal of hand surgery Vol 32A NO.8 October 2007</ref></u>
=== Technique  ===


[[Image:Mills test 1.png|frame|right|Mills test 1.png]]
The patient is seated, and the clinician palpates the patient’s lateral epicondyle with one hand while pronating the patient’s forearm, fully flexing the wrist, the elbow extended. A production of pain in the area of the insertion at the lateral epicondyle indicates a positive test.<ref name="Geoffroy P., et al." />


<br>In most cases the lesion involves the specialized junctional tissue (intercel adhesion molecules) at the origin of the common extensor muscle at the lateral humeral epicondyle, specifically the tendonous origin of Extensor carpi radialis brevis (ECRB) first time write in full. And in 35% of the cases the origo of m.extensor digitorum communis and ECRL will also be overstrained.<ref name="Pecina M. and Bojanic">Pecina M. Bojanic. Overuse injuries of the musculoskeletal system. CRC press Boca Rotan, USA, 1993</ref> The lesion is characterized by microscopic tears, which may be superficial or deep and situated at the tendinous origin of ECRB into the periosteum of the lateral humeral epicondyle. Microavulsion fractures may be seen as well as lymphocyte infiltration, calcification, scar tissue, and fibrinoid degeneration may be evident in some cases; repair is by immature fibroblasts.<ref name="Wadsworth T et al">Wadsworth T, Tennis elbow: conservative, surgical, and manipulative treatment. British medical journal Volume 294 7 March 1987</ref><ref name="Geoffroy P., et al.">Geoffroy P., et al. Diagnosing and treating lateral epicondylitis. Canadian Family Physician VOL 40: Jan 1994</ref>&nbsp;
{{#ev:youtube|gBReeVQqmpc}}<ref>Clinical Examination Videos. Tennis elbow test - Mills test. Available from: https://www.youtube.com/watch?v=gBReeVQqmpc [Accessed 9 November 2020]</ref>


<br>
=== Evidence ===
 
{| class="wikitable"
= Technique  =
!Sensitivity (%)
 
!Specificity (%)
1. Patient is seated.<br>2. The clinician palpates the patient’s lateral epicondyle with one hand, while pronating the patient’s forearm, fully flexing the wrist, the elbow extended. <br>3. A reproduction of pain in the area of the insertion at the lateral epicondyle indicates a positive test.<ref name="Geoffroy P., et al." /><br><br>  
!Positive Likelihood
!Negative Likelihood
|-
|53
|100
|~ (infinity)
|0.47
|}
<ref>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.</ref>


==== Other Techniques to Diagnose Lateral Epicondylitis  ====
==== Other Techniques to Diagnose Lateral Epicondylitis  ====


[[Maudsley's test|<u>Maudsley’s test</u>]] = Resisted third digit extension  
# [[Maudsley's test|Maudsley’s test]] - Resisted third digit extension
 
# [[Cozen’s Test|Cozen’s test]] - Resisted wrist extension with radial deviation and full pronation
[[Cozen’s Test|<u>Cozen’s test</u>]] = Resisted wrist extension with radial deviation and full pronation  
# Chair lift tes<u>t</u> - Lifting the back of a chair with a three-finger pinch (thumb, index long fingers) and the elbow fully extended.
 
=== Key Research  ===
<u>Chair lift test</u> = Lifting the back of a chair with a three finger pinch (thumb, index long fingers) and the elbow fully extended  
 
<br>
 
{{#ev:youtube|BoUTbHGwUEc|300}}
 
{{#ev:youtube|uzpqlSXBlgs|300}}
 
<br>
 
= Key Research  =
 
A study (By Tuomo Pienimäki et al. 2002) found that Pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and a positive Mills test, providing evidence.<ref name="Tuomo Pienimäki et al">Tuomo Pienimäki, M.D Ph.D et al. Associations Between Pain, Grip Strength, and Manual Tests in the Treatment Evaluation of Chronic Tennis Elbow . The clinical journal of pain 18: 164-170 2002</ref><br>
 
Wadsworth found that a forceful Mills movement under general anesthesia produces an audible snap and provides good results, although no scientific reason is given. Hereby giving evidence for the effectiveness of the movement itself.
 
The Mills test is a very straightforward test who is described in most of the physical therapy manuals. Knowing that expert opinion is only level 5 evidence, consensus about diagnostic effectiveness by a range of experts, can be used to make weak recommendations where there is lack of higher quality evidence.


More research is required.<br>  
A study (By Tuomo Pienimäki et al. 2002) found that pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and a positive Mills test, providing evidence.<ref name="Tuomo Pienimäki et al">Pienimäki T, Tarvainen T, Siira P, Malmivaara A, Vanharanta H. [https://journals.lww.com/clinicalpain/fulltext/2002/05000/associations_between_pain,_grip_strength,_and.5.aspx 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.</ref>  


<br>
Wadsworth found that a forceful Mills movement under general anaesthesia produces an audible snap and provides good results, although no scientific reason is given. Hereby giving evidence for the effectiveness of the movement itself.


= Resources  =
The Mills test is a very straightforward test that is described in most of the physical therapy manuals. Knowing that expert opinion is only level 5 evidence, consensus about diagnostic effectiveness by a range of experts can be used to make weak recommendations where there is a lack of higher-quality evidence.


The Mills test is named after the clinical findings by G Percival Mills, F.R.C.S who published his findings in The British Medical Journal (Jan 7th 1928)<ref name="G. Percival Mills">G. Percival Mills Treatment of tennis elbow. The British medical journal 12. Jan 7. 1928</ref> and updated this on July 31. 1937.<ref name="GP Mills">G. Percival Mills Treatment of tennis elbow. The British medical journal 212 July 31 1937</ref>
More research is required.  


<br>
=== Resources  ===


The Mills test is named after the clinical findings by G Percival Mills, F.R.C.S who published his findings in The British Medical Journal (Jan 7th 1928)<ref name="G. Percival Mills">G. Percival Mills Treatment of tennis elbow. The British medical journal 12. Jan 7. 1928</ref> and updated this on July 31. 1937.<ref name="GP Mills">Mills GP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2087033/ Treatment of tennis elbow.] British medical journal. 1937 Jul 31;2(3995):212.</ref>
== References  ==
== References  ==


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[[Category:Assessment]]
[[Category:Assessment]]
[[Category:Elbow - Assessment and Examination]]
[[Category:Elbow - Assessment and Examination]]
[[Category:Elbow - Special Tests]]

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Purpose[edit | edit source]

Mill's test aids in diagnosing Lateral Epicondylitis in the elbow, also known as “Tennis Elbow”.

Clinical presentation[edit | edit source]

Presenting equally in men and women, 1% to 3% of the population will experience lateral epicondylitis in their lifetime, usually between ages 35 and 50.[1][2] Patients report pain at the lateral elbow that radiates down the forearm. Also, patients often complain of a weakened grip and difficulties lifting objects. On physical examination, patients typically have point tenderness medial and distal to the lateral epicondyle.[3][4]

Condition Patient age Mechanism of injury Symptoms aggravated by Observation Tenderness with palpation

Lateral epicondylitis

35-55 Gradual overuse Activities involving wrist extension/grasping Possible swelling (over the lateral elbow) Lateral elbow (over extensor carpi radialis brevis)

Pathology[edit | edit source]

The histological aspects of the injury to the Extensor carpi radialis brevis (ECRB) origin appears to be multifaceted, involving hypovascular zones, eccentric & concentric tendon stresses, and a microscopic degenerative response.[5]
In most cases, the lesion involves the specialized junctional tissue (intercellular adhesion molecules) at the origin of the common extensor muscle at the lateral humeral epicondyle, specifically the tendinous origin of the Extensor Carpi Radialis Brevis (ECRB), and in 35% of the cases, the origin of the Extensor Carpi Radialis Longus (ECRL) will also be overstrained.[6] The lesion is characterized by microscopic tears, which may be superficial or deep and situated at the tendinous origin of ECRB into the periosteum of the lateral humeral epicondyle. Micro avulsion fractures may be seen as well as lymphocyte infiltration, calcification, scar tissue, and fibrinoid degeneration may be evident in some cases; repair is by immature fibroblasts.[7][8]

Technique[edit | edit source]

The patient is seated, and the clinician palpates the patient’s lateral epicondyle with one hand while pronating the patient’s forearm, fully flexing the wrist, the elbow extended. A production of pain in the area of the insertion at the lateral epicondyle indicates a positive test.[8]

[9]

Evidence[edit | edit source]

Sensitivity (%) Specificity (%) Positive Likelihood Negative Likelihood
53 100 ~ (infinity) 0.47

[10]

Other Techniques to Diagnose Lateral Epicondylitis[edit | edit source]

  1. Maudsley’s test - Resisted third digit extension
  2. Cozen’s test - Resisted wrist extension with radial deviation and full pronation
  3. Chair lift test - Lifting the back of a chair with a three-finger pinch (thumb, index long fingers) and the elbow fully extended.

Key Research[edit | edit source]

A study (By Tuomo Pienimäki et al. 2002) found that pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and a positive Mills test, providing evidence.[11]

Wadsworth found that a forceful Mills movement under general anaesthesia produces an audible snap and provides good results, although no scientific reason is given. Hereby giving evidence for the effectiveness of the movement itself.

The Mills test is a very straightforward test that is described in most of the physical therapy manuals. Knowing that expert opinion is only level 5 evidence, consensus about diagnostic effectiveness by a range of experts can be used to make weak recommendations where there is a lack of higher-quality evidence.

More research is required.

Resources[edit | edit source]

The Mills test is named after the clinical findings by G Percival Mills, F.R.C.S who published his findings in The British Medical Journal (Jan 7th 1928)[12] and updated this on July 31. 1937.[13]

References[edit | edit source]

  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 7;294(6572):621.
  8. ↑ 8.0 8.1 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. ↑ G. Percival Mills Treatment of tennis elbow. The British medical journal 12. Jan 7. 1928
  13. ↑ Mills GP. Treatment of tennis elbow. British medical journal. 1937 Jul 31;2(3995):212.
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