Bicep tear test: Hook test, Yergason’s, and when to use each

Key takeaways

A bicep tear test is a hands-on examination that checks the biceps tendon before you order any imaging.

The hook test is the gold standard for a complete distal rupture, with sensitivity and specificity close to 100%.

Pairing the hook test with the biceps crease interval was the most accurate combination in a cohort of 86 patients.

Partial tears often produce a negative hook test, so the TILT sign and passive forearm pronation test carry the diagnosis.

Practice management software like Pabau gives every clinician the same examination fields, so findings read the same way in every record.

A patient lifts a heavy box, feels a pop at the front of the elbow, and turns up two days later with bruising. One question decides everything that follows. Is the biceps tendon still attached?

A bicep tear test answers that at the bedside, before anyone books imaging. The catch is that the phrase covers several maneuvers, and each one reads a different part of the tendon.

A hook test checks the distal insertion at the elbow. Yergason’s test looks at the long head, up at the shoulder. Choose the wrong end and a genuine rupture can examine as normal.

Test selection therefore starts with anatomy rather than with a list of names. Get the site right, and the rest of the examination falls into a clear order. Miss it, and you either lose a repair window or send a low-risk patient for scans they never needed.

Where the tendon tore decides which test you use

Test choice comes down to one anatomical fact. The biceps has two ends, and they fail in different ways.

The muscle has two heads. Its short head starts at the coracoid process. The long head, usually shortened to LHBT, starts at the supraglenoid tubercle and runs through the bicipital groove at the shoulder. Both heads converge into one distal tendon that inserts at the radial tuberosity.

That distal tendon has a partner. The bicipital aponeurosis, also called the lacertus fibrosus, fans out to the ulnar fascia and tethers the muscle after a rupture. That tether explains why some torn tendons retract only a little, and why a rushed examination can miss them.

Those two failure sites produce two very different clinical pictures.

Symptoms that tell you which end of the tendon failed

History does most of the sorting before you touch the arm. A distal rupture usually arrives as sudden, sharp pain at the front of the elbow. Many patients also describe an audible pop during a loaded eccentric contraction. Proximal long head ruptures build more slowly, with anterior shoulder pain that has been grumbling for weeks.

• Sudden pop or snap at the moment of injury, more common distally than proximally
• Bruising that tracks down the forearm within 24 to 48 hours, which points to a distal rupture
• Palpable defect at the front of the elbow or in the bicipital groove
• Popeye deformity, where the retracted muscle belly leaves a visible bulge in the mid upper arm. It is classic for a proximal LHBT rupture, can appear in distal tears, and may be subtle in heavier patients
• Weakness of forearm supination, most pronounced in distal ruptures, where the biceps supplies 40-50% of supination torque
• Weakness of elbow flexion in both, though usually modest proximally because the brachialis compensates

One pattern needs no debate. A patient who lifted something heavy, felt a pop, and now has bruising at the elbow has a distal rupture until proven otherwise. Start with the hook test.

The hook test is the gold standard for distal ruptures

The hook test, first described by O’Driscoll, is the most reliable bedside test for a complete distal biceps rupture. Sensitivity and specificity both approach 100% for complete tears in the original series and in later systematic reviews. Nothing else in this article comes close.

How to perform the hook test

1. Seat or stand the patient with the elbow flexed to 90 degrees and the forearm actively supinated.
2. Approach from the lateral side of the front of the elbow.
3. Hook your index finger under the cord-like distal tendon, moving from lateral to medial.
4. With an intact tendon you can hook about 1 cm of firm cord. Inability to hook anything is a positive test.

Positive result: complete distal biceps rupture. The tendon has retracted and there is nothing to hook. No further examination will tell you more. MRI may still follow for surgical planning, but the diagnosis is already made.

Negative result: the tendon is intact, or torn only in part. A negative hook test does not rule out a partial tear, so move on to the partial tear tests further down.

Technique errors that fake a normal hook test

The accuracy figures above assume the test is done properly. Four errors account for most false negatives.

• Approaching from the medial side. Your finger can catch the bicipital aponeurosis instead, which often stays intact after a rupture. A torn tendon then feels present.
• Settling for partial supination. Full active supination tightens the tendon and lifts it into a cord. Without it, even a healthy tendon is hard to find.
• Testing with the elbow too straight. Ninety degrees of flexion is what gives your finger room underneath the tendon.
• Accepting a guarded arm. Pain limits supination in the first few days. Record that the test was limited rather than logging it as negative.

Pair the hook test with the biceps crease interval

The hook test tells you whether the tendon is there. Measuring the biceps crease interval, or BCI, tells you how far the muscle has traveled. Together they answer two halves of the same question.

Sit the patient with the elbow at 90 degrees and fixate the wrist. Passively extend the elbow and supinate the forearm. Mark the flexion crease at the front of the elbow, then mark where the biceps curve starts. Measure the distance between the two marks.

More than 6 cm indicates a complete distal rupture. Repeat the measurement on the other arm and you have the biceps crease ratio, where anything above 1.2 points the same way. In a cohort of 86 patients, a positive hook test plus a positive BCI was the most accurate combination. That held true for acute and chronic ruptures alike.

Yergason’s test moves the examination to the shoulder

Yergason’s test targets the long head of the biceps at the shoulder. Reach for it when the patient has anterior shoulder pain, a history that fits proximal pathology, or a SLAP lesion on the differential.

How to perform Yergason’s test

1. Seat the patient with the elbow flexed to 90 degrees and the forearm pronated.
2. Stabilize the patient’s elbow against their body.
3. Ask the patient to supinate the forearm and externally rotate the shoulder while you resist both movements.
4. Pain or a snap at the bicipital groove is a positive test.

Yergason’s test is nowhere near as decisive as the hook test. Published studies report sensitivity between 27% and 43%, with specificity between 79% and 86% for long head pathology. A negative result therefore excludes very little.

Combine it with Speed’s test, or with imaging, when suspicion stays high. Where a SLAP lesion looks more likely than tendon pathology, the biceps load test is the better follow-up maneuver.

Weakness on abduction changes the question altogether. A positive drop arm test moves attention to the rotator cuff, which often sits alongside long head pathology in older patients.

The squeeze test earns its place when the patient cannot cooperate

The biceps squeeze test is the distal alternative when a hook test is not possible. It works on the same principle as the Thompson test for Achilles tendon rupture. You squeeze the muscle and watch for the movement an intact tendon should produce.

How to perform the biceps squeeze test

1. Position the patient with the elbow flexed between 60 and 80 degrees.
2. Squeeze the biceps muscle belly firmly in the mid upper arm.
3. Watch the forearm for passive supination.
4. Supination means the muscle and tendon unit is intact. No supination indicates a distal rupture.

Sensitivity is lower than the hook test for complete ruptures. Even so, it corroborates well in the acute setting, where pain limits how much the patient can help you.

Partial tears need a different pair of tests

Partial tears are where bedside examination gets hard. Enough fibers remain to hook, so the hook test reads negative while the patient still has pain and weakness. Two tests carry most of the diagnostic weight in that situation.

TILT sign

Put the forearm in full pronation and palpate the radial tuberosity. Your window is the interval between the extensor carpi radialis brevis and the extensor digitorum communis. Tenderness there is a positive TILT sign.

One small study reported 100% sensitivity for partial distal tears, though external validation remains thin. Treat a positive sign as a reason to image, not as a diagnosis in its own right. Note the exact spot of tenderness and the arm position that reproduced it. A vague note here sends the next clinician back to square one.

Passive forearm pronation test

Flex the elbow to 90 degrees, hold the forearm in neutral, then passively pronate it fully. Pain at the front of the elbow suggests fibers that are intact but injured, and under tension.

Watch the muscle belly while you rotate the forearm, not the patient’s face. An intact tendon pulls the belly proximally in supination and lets it migrate distally in pronation. No excursion at all points to a complete rupture. A painful test with normal excursion points to a partial one.

Line up a positive TILT sign, a painful pronation test, and a negative hook test. That combination is a partial tear worth confirming on MRI or dynamic ultrasound before you commit to a plan.

Diagnostic accuracy of every bicep tear test, side by side

No single publication lines all of these tests up in one place, which is why the table below exists. The figures come from O’Driscoll’s original series, later systematic reviews, and a cohort study that examined the tests together in 86 patients. Read the partial tear rows with more caution than the rest, because the samples behind them are small.

*TILT sign sensitivity comes from a single small study, so interpret it with caution until further validation arrives.

What imaging adds after the examination

A positive hook test in a complete distal rupture may not need MRI before referral, because the clinical diagnosis is already established. MRI earns its place in three situations.

• Suspected partial tear: MRI is the gold standard for measuring how much of the tendon is involved, which guides the operative or conservative call.
• Equivocal examination: when the hook test is negative but suspicion stays high, MRI or dynamic ultrasound can confirm whether the tendon is continuous.
• Preoperative planning: MRI shows the degree of retraction and the state of the bicipital aponeurosis, both of which shape the surgical approach and its timing.

Ultrasound has its own strengths. It is dynamic, cheaper, and good for watching the distal tendon during forearm rotation. Results do depend on the operator, though. MRI stays the better choice when the extent of a partial tear has to be pinned down precisely.

Complete vs partial tear: What changes in management

Sorting complete from partial is the decision your whole examination has been building toward. Treatment paths separate sharply from that point.

Who needs surgery, and who can be managed without it

Three things drive the decision after a positive test. They are the tear site, how complete the tear is, and what the patient needs the arm to do.

Distal complete tears in active patients. Reattachment to the radial tuberosity is the standard recommendation. Comparative studies show that operative repair restores supination strength better than conservative care, particularly in manual workers and athletes. Early repair, within 3 to 4 weeks of injury, beats delayed repair, because retraction and scarring set in quickly.

Proximal LHBT ruptures in low-demand patients. Conservative care suits the majority of these. The brachialis preserves elbow flexion strength, and supination deficits stay modest. Plenty of patients accept the cosmetic Popeye deformity without any real loss of function.

Partial tears. Rest, eccentric loading, and either corticosteroid or regenerative injection therapies handle most of these at first. Surgery comes onto the table when 3 to 6 months of conservative treatment fails.

Whichever path a patient takes, the home program does much of the work between visits. A biceps tendonitis exercises handout gives them something concrete to follow, which beats verbal instructions they will half remember by Thursday.

Recovery timelines your patients will ask about

Recovery depends on tear location, completeness, and the treatment path. The ranges below are the accepted ones, though age, baseline function, and adherence move them in both directions.

• Distal complete tear, surgically repaired: protected range of motion starts at 2 weeks, and progressive strengthening at 6 to 8 weeks. Heavy manual work or sport returns at 4 to 6 months. Full supination strength can take up to 12 months.
• Proximal LHBT rupture, managed conservatively: most patients reach functional recovery within 4 to 12 weeks. Physical therapy targets the rotator cuff and shoulder girdle.
• Partial tear, managed conservatively: timelines vary. Tears involving less than half the tendon often settle with 8 to 12 weeks of structured physical therapy. Larger partial tears can take 3 to 6 months.

Post-operative distal repairs need loading in a set order. Return-to-sport protocols add supination and flexion demand step by step before full clearance, which protects the repair while strength returns.

Practices running a physical therapy EMR can track those milestones against fixed criteria. A plateau then shows up in week 8, rather than in month 4 when the patient mentions it in passing.

Before you refer: What belongs in the note

A referral that says only “hook test positive” gives the receiving team almost nothing. The surgeon reading it needs to know how you tested and what you found. Run through this list before the letter leaves your desk.

• Date and mechanism of injury, including the arm position at the time
• Elbow flexion angle and forearm position used for each test
• The side you approached from, and how much tendon you could hook
• Supination and flexion strength, graded against the other arm
• Whether pain or swelling limited any part of the examination
• Imaging already done, plus anything you have requested

Two habits cause most of the confusion further down the line. One is recording a result without the technique, which makes a true negative impossible to tell apart from a poorly performed test. The other is burying the finding in free text, where the next clinician has to hunt for it.

A structured template fixes both. Keeping the examination in a SOAP progress notes format puts the finding in the same field every time. Week 6 can then be compared with week 1 in seconds.

How Pabau keeps examination findings consistent across a team

In a lot of practices, special tests get written down wherever there is space in the note. One clinician types “hook test neg”, another writes a paragraph, and a third leaves out arm position entirely. Six weeks later nobody can say whether the patient improved or whether the second examiner simply tested differently.

Practice management software like Pabau replaces that with fixed fields. You build one upper limb assessment template, with elbow angle, approach side, hook result, and graded strength as separate entries.

Every clinician then completes the same form. Patient record management keeps it attached to the patient file, instead of a document somebody saved to a shared drive.

The payoff arrives at review and at referral. Strength deficits line up date by date, so a plateau is obvious rather than debatable. Audit stops being an archaeology exercise. For sports medicine practices running high assessment volumes, that consistency is what makes outcome tracking possible at all.

Keep every examination note consistent

Pabau gives your team one set of examination fields for musculoskeletal assessments. Hook test findings, strength grades, and follow-up plans all stay in the patient record. See how it fits your practice.

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Conclusion

Anatomy picks the test, and the test picks the pathway. Reach for the hook test when a complete distal rupture is likely. Yergason’s test belongs at the shoulder, on the long head.

The TILT sign and passive pronation earn their place once a partial tear is in play. Add the biceps crease interval when you want a number instead of an impression.

The trade-off worth remembering is that near-perfect accuracy applies to complete tears only. A negative hook test settles nothing in a painful, weak arm. That is the moment to slow down rather than reassure.

Record the technique alongside the result and the next clinician can trust your examination instead of repeating it. Book a demo to see how Pabau structures examination templates and patient records for sports medicine and physical therapy teams.

Continue your research

Ruling out elbow instability alongside a tendon injury? Lateral pivot shift test walks through the maneuver that exposes posterolateral rotatory instability.

Anterior elbow pain without a rupture on examination? Cozen’s test covers the lateral epicondyle screen that often sits on the same differential.

Managing stiffness after an elbow repair? Elbow stiffness exercises gives patients a printable program for the range of motion phase.

Worried your examination notes would not survive a review? Safer clinical notes sets out what to include and how to structure findings for medico-legal clarity.

Spending your evenings writing up assessments? Clinical notes AI explains how dictation and AI drafting shorten documentation time without thinning the detail.

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