The Milking Manoeuvre Test is an elbow special test used to apply valgus stress to the medial elbow and reproduce symptoms associated with the ulnar collateral ligament, particularly in overhead-throwing athletes. The test is usually performed with the elbow flexed beyond 90 degrees and the forearm supinated while the professional pulls on the client’s thumb to create a valgus load.
A positive finding may include familiar medial elbow pain, apprehension, instability sensation or symptom reproduction during the valgus stress. However, the test does not confirm UCL injury on its own. It should be interpreted alongside throwing history, mechanism, medial elbow tenderness, valgus stress testing, moving valgus stress testing, grip strength, neurological screening, imaging where relevant and professional judgement.
The Milking Manoeuvre Test is a classic elbow special test used when medial elbow pain or ulnar collateral ligament involvement is part of the assessment reasoning. The UCL, especially the anterior bundle, is a major restraint to valgus stress at the elbow. It is particularly important in overhead throwing, where high valgus loads occur during the late cocking and acceleration phases.
The test is often used for baseball pitchers, javelin throwers, cricket bowlers, tennis players and other athletes or clients exposed to repeated valgus elbow loading. It can also be used after a valgus trauma mechanism, although its strongest practical relevance is usually in throwing or overhead-load contexts.
The Milking Manoeuvre creates valgus stress by positioning the elbow in flexion and pulling the thumb. If this reproduces familiar medial elbow pain or instability symptoms, the finding may support UCL-related assessment reasoning.
However, the test should not be used as a stand-alone diagnostic test. Medial elbow pain may also involve the flexor-pronator mass, ulnar nerve, medial epicondyle, joint irritation, growth-related conditions in younger athletes, or referred symptoms. In throwing athletes, a small amount of valgus laxity may be present without symptoms, so pain, history and functional context matter.
Test name: Milking Manoeuvre Test
Region: Elbow
Primary purpose: Provoke medial elbow symptoms with valgus stress
Commonly associated presentation: Ulnar collateral ligament involvement, valgus overload, medial elbow symptoms in overhead throwers
Positive finding: Familiar medial elbow pain, apprehension, instability sensation or symptom reproduction
Negative finding: No familiar medial elbow symptoms and no meaningful side-to-side difference
Main limitation: Diagnostic accuracy evidence for the Milking Manoeuvre as a stand-alone test is limited and should be interpreted cautiously.
The Milking Manoeuvre Test is a valgus stress test for the medial elbow.
The client’s elbow is flexed beyond 90 degrees, the forearm is supinated, and the professional applies a valgus load by pulling downward on the client’s thumb. This places stress across the medial elbow and may reproduce symptoms associated with the ulnar collateral ligament.
The test may be performed in sitting, standing or supine depending on the professional’s preference and the client’s comfort.
The test may be used to observe:
Medial elbow pain
UCL-region symptom reproduction
Apprehension
Instability sensation
Side-to-side difference
Symptom location
Relationship to throwing history
The Milking Manoeuvre Test may be used to support assessment reasoning around:
Medial elbow pain
Ulnar collateral ligament involvement
Valgus overload in throwing athletes
Pain during late cocking or acceleration phases of throwing
Elbow instability sensation
Medial elbow symptoms after valgus stress
Flexor-pronator versus UCL differential reasoning
Side-to-side comparison
Baseline and retest documentation in Measurz
The test is especially useful when symptoms are related to overhead throwing or valgus-load tasks.
The Milking Manoeuvre Test assesses symptom response to valgus stress across the medial elbow in a flexed position.
It may provide information about:
Medial elbow symptom reproduction
UCL-related assessment reasoning
Apprehension under valgus load
Instability sensation
Side-to-side symptom difference
Throwing-related elbow irritability
Whether valgus stress reproduces familiar symptoms
It does not directly assess:
UCL fibre integrity with certainty
Tear grade with certainty
MRI findings
Exact laxity amount
Flexor-pronator pathology
Ulnar nerve involvement
Throwing readiness
Work readiness
Treatment need
The Milking Manoeuvre Test may be useful for clients with:
Medial elbow pain
Throwing-related elbow symptoms
Symptoms during overhead sport
Pain with valgus elbow loading
Apprehension or instability sensation at the elbow
Symptoms after a valgus stress mechanism
Suspected UCL-related presentation
Need for baseline and retest documentation in Measurz
It may also be useful for professionals learning how elbow position and valgus loading influence medial elbow symptoms.
Consider using the Milking Manoeuvre Test when:
The client reports medial elbow pain during throwing
UCL involvement is part of the assessment reasoning
Valgus loading reproduces symptoms
The client has pain in the late cocking phase of throwing
Moving Valgus Stress Test or valgus stress testing is being considered
You need a side-to-side comparison
You are building a broader elbow assessment profile
It should be combined with history, palpation, valgus stress testing, Moving Valgus Stress Test, resisted wrist flexion/pronation, ulnar nerve assessment and sport-specific load history.
Use caution or avoid the test when:
Recent fracture, dislocation or major trauma is suspected
The elbow is highly irritable
Severe pain is present before testing
The client cannot tolerate elbow flexion
Neurological symptoms are severe or worsening
Growth-plate or adolescent throwing-related concerns require further assessment
The professional cannot apply controlled valgus stress safely
The test would not change assessment reasoning
Stop the test if pain increases sharply, the client reports strong instability, neurological symptoms appear or worsen, or the client asks to stop.
The Milking Manoeuvre Test usually requires no equipment.
Optional equipment includes:
Measurz app
Pain rating scale
Throwing-history notes
Elbow range of motion record
Grip strength or pinch strength tool
Notes field for valgus stress response
Video recording for education where appropriate
Imaging or referral notes if relevant
Ask the client to sit or stand comfortably.
Explain the test:
“I am going to place your elbow in a flexed position and apply a gentle valgus stress through your thumb. Tell me if this reproduces your familiar medial elbow symptoms or any feeling of instability.”
Test the less symptomatic side first where appropriate.
The client may sit or stand with:
Shoulder elevated, abducted or positioned in a throwing-like posture depending on the variation
Elbow flexed beyond 90 degrees
Forearm supinated
Wrist and hand relaxed
Thumb accessible to the professional
The client should not actively resist unless instructed.
The professional stands beside or in front of the client.
They should be able to support the elbow and apply controlled traction through the thumb without twisting the wrist aggressively.
One hand may support the elbow or upper limb.
The other hand grasps the client’s thumb.
Avoid painful gripping of the thumb or wrist.
Stabilise the upper arm enough to control the movement and direct force to the elbow.
Avoid excessive shoulder movement, wrist twisting or uncontrolled pulling.
Apply a downward traction force through the thumb to create valgus stress at the elbow.
The force should be:
Gentle
Gradual
Controlled
Symptom-limited
Compared with the other side where appropriate
Tell the client:
“Stay relaxed. Tell me if you feel your familiar medial elbow pain, apprehension, instability or symptoms down into the forearm or hand.”
A positive finding may include:
Familiar medial elbow pain
UCL-region pain
Apprehension
Instability sensation
Symptoms reproduced in a throwing-relevant position
Clear side-to-side difference
Pain that matches the client’s throwing complaint
Record whether the positive finding was pain, apprehension, instability sensation or a combination.
A negative finding may include:
No familiar medial elbow pain
No apprehension
No instability sensation
No meaningful side-to-side difference
Only mild non-familiar stretch or pressure
A negative finding does not fully exclude UCL involvement.
Stop the test if:
Pain increases sharply
Instability sensation becomes strong
Ulnar nerve symptoms occur or worsen
The client asks to stop
The test position cannot be tolerated
The professional cannot control the force safely
The test should be symptom-limited. Avoid aggressive valgus loading, especially after acute trauma or in highly irritable throwing elbows.
A positive Milking Manoeuvre Test may increase suspicion that the UCL or medial elbow structures are relevant to the client’s symptoms, especially when it reproduces familiar throwing-related medial elbow pain. Apprehension or instability sensation may also be meaningful when it matches the history.
However, a positive test does not confirm a UCL tear. Medial elbow symptoms can also arise from the flexor-pronator mass, ulnar nerve irritation, medial epicondyle irritation, joint irritation or other elbow conditions.
A negative Milking Manoeuvre Test may reduce suspicion that this specific valgus stress position reproduces symptoms in that session. However, it does not exclude UCL involvement, particularly when symptoms occur only during high-speed throwing, fatigue, or sport-specific loads.
The result is more meaningful when interpreted with:
Throwing history
Symptom timing during throwing
Medial elbow palpation
Valgus Stress Test
Moving Valgus Stress Test
Flexor-pronator strength testing
Ulnar nerve assessment
Grip and pinch strength
Shoulder and trunk contribution
Imaging where relevant
Diagnostic accuracy evidence for the Milking Manoeuvre as a stand-alone test is limited compared with broader elbow UCL assessment.
Recent clinical discussion and research around medial ulnar collateral ligament assessment suggests that the Milking Manoeuvre may be useful for identifying whether the UCL is symptomatic, while valgus stress testing may provide more information about laxity. The Moving Valgus Stress Test has often been discussed as a highly sensitive test in UCL assessment, while the Milking Manoeuvre is commonly used as a complementary provocation test.
Condition or presentation: Medial ulnar collateral ligament injury / symptomatic UCL involvement
Population: Primarily overhead-throwing athletes and medial elbow pain populations
Test variation: Standard or modified Milking Manoeuvre
Reference standard: Varies across research and clinical reports, including imaging, surgical findings and clinical diagnosis
Sensitivity: Not consistently established for the standard Milking Manoeuvre across high-quality studies
Specificity: Not consistently established across high-quality studies
Likelihood ratios: Not consistently available for stand-alone interpretation
Key limitations: Different test variations, different elbow positions, small or specialised athlete populations and overlap with other medial elbow conditions.
Plain-language interpretation:
A positive test may support suspicion when it reproduces familiar medial elbow symptoms.
A negative test does not exclude UCL involvement.
The test is more useful in a cluster than alone.
Throwing athletes may show some laxity without symptoms, so symptom reproduction matters.
Reliability evidence for the Milking Manoeuvre is limited and depends on consistent technique.
Reliability may be affected by:
Shoulder position
Elbow flexion angle
Forearm supination position
Amount of thumb traction
Direction of valgus force
Client guarding
Symptom irritability
Whether pain, apprehension or laxity is used as the positive criterion
Professional experience with throwing-athlete elbows
Validity is strongest when the test is used as a symptom provocation test in a relevant medial elbow history. Validity is weaker if it is used alone to infer UCL structural integrity or tear grade.
Reliability improves when the professional records:
Elbow angle
Shoulder position
Forearm position
Force direction
Symptom location
Pain score
Apprehension
Side-to-side comparison
Related valgus tests
Common errors include:
Pulling too aggressively on the thumb
Not supporting the arm
Not recording elbow flexion angle
Not confirming symptoms are familiar
Counting vague discomfort as a clear positive
Ignoring ulnar nerve symptoms
Not comparing sides
Assuming pain confirms UCL tear
Assuming a negative test excludes UCL involvement
Not assessing the flexor-pronator mass
Limitations include:
Stand-alone diagnostic accuracy is not well established
It may be uncomfortable at the thumb or wrist
Medial elbow pain is not specific to UCL injury
Throwing symptoms may not reproduce in static testing
Laxity may occur in asymptomatic throwers
Test technique varies between professionals
A single test should not guide throwing or sport decisions
The Milking Manoeuvre Test may be useful for:
Medial elbow symptom provocation
UCL-related assessment reasoning
Throwing-athlete elbow assessment
Comparing sides
Recording pain versus apprehension
Baseline and retest documentation
Deciding whether further assessment may be appropriate
Supporting Measurz elbow assessment reports
In Measurz, it can be recorded alongside Valgus Stress Test, Moving Valgus Stress Test, flexor-pronator strength, grip strength, ulnar nerve testing, shoulder range of motion, scapular assessment and throwing workload history.
Record:
Test name: Milking Manoeuvre Test
Side tested
Shoulder position
Elbow flexion angle
Forearm position
Result: positive, negative, unclear or unable to test
Pain score
Symptom location
Whether symptoms were familiar
Apprehension
Instability sensation
Ulnar nerve symptoms if present
Force direction
Comparison side
Throwing phase or task that matches symptoms
Irritability
Reason for stopping if relevant
Related valgus test findings
Related strength findings
Confidence in interpretation
Further assessment or referral notes if appropriate
Retest date if relevant
Recording these details improves repeatability, communication, client education, assessment reasoning, monitoring over time, team consistency and reporting quality.
Moving Valgus Stress Test
Valgus Stress Test of the Elbow
Ulnar Nerve Assessment
Elbow Flexion Test
Grip Strength
Pinch Strength
Wrist Flexion Strength
Forearm Pronation Strength
Shoulder Range of Motion
Scapular Assistance Test
Throwing Assessment Notes
It assesses whether valgus stress in a flexed elbow position reproduces medial elbow symptoms associated with UCL-related assessment reasoning.
A positive finding may include familiar medial elbow pain, apprehension, instability sensation or symptom reproduction during the valgus stress.
No. It may increase suspicion, but it does not confirm a UCL tear on its own.
No. A negative test does not fully exclude UCL involvement, especially in throwing athletes with symptoms only during high-speed sport tasks.
It is most useful for overhead athletes or clients with valgus-load medial elbow symptoms.
Yes. Tingling, numbness or altered sensation into the ulnar hand should be recorded and interpreted separately.
No. Some throwing athletes may have mild valgus laxity without symptoms, so symptom reproduction and history are critical.
Throwing history, palpation, Valgus Stress Test, Moving Valgus Stress Test, flexor-pronator testing, ulnar nerve assessment and imaging where relevant.
The Milking Manoeuvre Test applies valgus stress to the medial elbow by pulling through the thumb.
It is commonly used in UCL assessment reasoning, particularly in overhead throwers.
A positive finding is most meaningful when it reproduces familiar medial elbow symptoms.
The test does not confirm a UCL tear or grade injury severity on its own.
Diagnostic accuracy evidence for the Milking Manoeuvre as a stand-alone test is limited.
Measurz recording should include elbow angle, shoulder position, pain location, symptom familiarity, apprehension, instability sensation and comparison side.
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O’Driscoll, S. W., Lawton, R. L., & Smith, A. M. (2005). The “moving valgus stress test” for medial collateral ligament tears of the elbow. The American Journal of Sports Medicine, 33(2), 231–239. https://doi.org/10.1177/0363546504267804
Veltri, D. M., O’Brien, S. J., Field, L. D., Deutsch, A., Altchek, D. W., & Potter, H. G. (1995). The milking maneuver: A new test to evaluate the medial collateral ligament of the elbow in the throwing athlete. Journal of Shoulder and Elbow Surgery, 4(1), S10. https://doi.org/10.1016/S1058-2746(95)80048-4
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Zaremski, J. L., McClelland, J., Vincent, H. K., & Horodyski, M. (2025). Diagnostic dilemma: Testing to differentiate UCL sprains from flexor-pronator elbow strains in the overhead athlete. International Journal of Sports Physical Therapy.
