The hook test for distal biceps tendon avulsion

Background: Complete biceps tendon avulsions are frequently missed on clinical examination, suggesting the need for a reliable diagnostic test. Hypothesis: Complete distal biceps avulsions can be reliably detected with the Hook test. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The hook test was performed by a single surgeon in a cohort of 45 patients undergoing surgical exploration of the distal biceps tendon. While the patient actively supinates with the elbow flexed 90 degrees, an intact hook test permits the examiner to hook his or her index finger under the intact biceps tendon from the lateral side. With an abnormal hook test, indicating distal avulsion, there is no cord-like structure under which the examiner may hook a finger. Results: Thirty-three patients had an avulsion and 12 had a partial tear. The hook test was abnormal in 33 of 33 (100%) patients with complete biceps avulsions, and intact in 12 of 12 with partial detachments. However, it was painful in 9 of those 12. In the noninjured contralateral arms, which served as the normal control group, 45 of 45 (100%) had a normal hook test. Magnetic resonance imaging (MRI) diagnosed a complete tear in 11 of 12 patients with partial tears and in 11 of 13 with complete lesions. The sensitivity and specificity were both higher with the hook test (both 100%) than with MRI (92% and 85%, respectively). Conclusions: The hook test is a highly sensitive and specific test for assessment of distal biceps tendon avulsions.