Milking Maneuver Overview

Milking Maneuver is used to evaluate the posterior band of the medial ulnar collateral ligament (Valgus Instability) of the elbow joint.

How to Perform the Milking Maneuver?

• The patient is seated and the arm is positioned in shoulder flexion, the elbow is flexed beyond 90 degrees, and the forearm is in supination.
• The clinician pulls downward on the patient’s thumb imparting a valgus stress to the elbow.
• This maneuver generates a valgus stress on the flexed elbow.
• The tests are repeated on the opposite extremity and the findings compared.

It has been suggested that abducting and laterally rotating the shoulder with the elbow at 70° and a valgus stress applied by the examiner’s thumb can be used as part of the milking motion (Modified Milking Maneuver – See Later).

See Also: Elbow Anatomy

What does a positive Milking Maneuver mean?

Positive Milking Maneuver if there is apprehension, instability, or pain at the medial collateral ligament origin of the elbow.

Modified Milking Maneuver

To assess injuries to the medial collateral ligament, the positioning of the shoulder should be in adduction and full external rotation. The forearm should be placed in supination along with 70° of elbow flexion. The clinician should then pull the patient’s thumb with one hand to create valgus stress. The medial joint line is palpated using the other hand while the valgus stress is applied.

Pain, laxity, and/or apprehension about the medial elbow by the patient reflects a positive test.

Notes

Medial or ulnar collateral ligament (MCL or UCL) has three bundles: anterior, posterior, and transverse bundles. It arises from the anteroinferior portion of the medial humeral epicondyle and is the primary static stabilizer to valgus stress.

Anterior bundle is the most important in helping resist valgus forces and attaches 18 mm distal to the coronoid tip at the sublime tubercle. Valgus stability with the arm in pronation suggests that the anterior bundle of the UCL is intact.

Posterior bundle: greatest change in length from flexion to extension. It’s best tested using a milking maneuver.

No diagnostic accuracy studies have been performed to determine the sensitivity or specificity of the Milking Maneuver test.

Reference

• Karbach LE, Elfar J. Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am. 2017 Feb;42(2):118-126. doi: 10.1016/j.jhsa.2016.11.025. PMID: 28160902; PMCID: PMC5821063.
• Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010 Oct;29(4):619-44. doi: 10.1016/j.csm.2010.06.007. PMID: 20883901.
• Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014;89(8):649–657. Pubmed
• Mark Dutton, Pt . Dutton’s Orthopaedic Examination, Evaluation, And Intervention, 3rd Edition Book.
• Millers Review of Orthopaedics, 7th Edition Book.
• Campbel’s Operative Orthopaedics 13th edition book.