Hand Surgery Source

Tinel's Sign: Median

Test, Exam and Signs

Historical Perspective1

  • 1915: Paul Hoffman (1884-1962), a German physiologist, described a sensation of “tingling” or “pins and needles” that could be elicited when an injured nerve was percussed and attributed the sign to nerve regeneration.
  • 1915: Jules Tinel (1879-1952), a French neurologist, described a “tingling sensation” or “formication sign” after slight percussion of a nerve trunk after injury to which he attributed the sensation to the presence of growing axons.
  • 1957: George Phalen (1911-1998), an American hand surgeon, was the first to describe the usefulness of the Tinel sign in diagnosing carpal tunnel syndrome (CTS).

Description1

  • Tinel’s sign over the median nerve is described as a tingling sensation in the thumb, index and middle finger after light tapping or percussion over that nerve.
  • A true Tinel’s sign may be uncomfortable for the patient, but it is never painful.

Pathophysiology1

  • May involve abnormal mechanosensitivity of the median nerve resulting in afferent discharge of regenerating nerves.
  • On a cellular level, the sign may be caused by a hyper-excitable membrane.

Instructions1

  1. Tap over the median nerve as it passes through the carpal tunnel in the wrist.
  2. The intensity of the tapping should be enough to cause the expected response while avoiding direct mechanical stimulation of the median nerve.

Variations2

  • Single-finger strike: striking the load cell with the dominant middle finger only
  • Double-finger strike: striking the load cell with the dominant index and middle finger together
  • Preload: preloading with the non-dominant thumb and then striking the thumb with the dominant middle finger

Related Signs and Tests

  • Phalen’s or Reversed Phalen’s maneuver
  • Carpal tunnel compression test
  • Durkan’s compression test
  • Hoffmann-Tinel’s sign
  • Hand elevation test
  • Tourniquet test
  • Pressure aesthesiometry
  • Semmes-Weinstein monofilament testing
  • Median nerve stress test

Diagnostic Performance Characteristics

Citation

Sensitivity*

Specificity†

PPV‡

NPV§

Accuracyǁ

Szabo et al, 19993

64%

71%

 

 

 

Wiseman et al, 20034

62%

93%

88%

76%

 

MacDermid & Wessel, 20045

50%

77%

 

 

 

LaJoie et al, 20056

97%

91%

 

 

 

Wainner et al, 20057

A=41%;
B=48%

A=58%;
B=67%

 

 

 

AAOS, 20078

28-73%

44-95%

 

 

 

Cheng et al, 20089

32%

99%

96%

59%

65%

*Sensitivity: true positive rate; proportion of actual positives that are correctly identified as such

†Specificity: true negative rate; proportion of actual negatives that are correctly identified as such

‡Positive predictive value (PPV): measure of precision; true positives / total number of positives (depends on prevalence)

§Negative predictive value (NPV): true negatives / total number of negatives (depends on prevalence)

ǁAccuracy: proportion of true results (positive and negative) in the population
Presentation Photos and Related Diagrams
  • TINEL'S SIGN MEDIAN NERVE - This test is done by tapping on the median nerve just proximal to the wrist crease. The wrist is held in 30 degrees of dorsiflexion while the nerve is percussed. The wrist should be held loosely so that the patient doesn't tighten his volar ligaments and muscles during the test.
    TINEL'S SIGN MEDIAN NERVE - This test is done by tapping on the median nerve just proximal to the wrist crease. The wrist is held in 30 degrees of dorsiflexion while the nerve is percussed. The wrist should be held loosely so that the patient doesn't tighten his volar ligaments and muscles during the test.
Definition of Positive Result

Positive Tinel's Sign

  • When tapping on the median nerve just proximal to wrist crease the patient experiences paresthesias in the all or part of the median nerve distribution which includes the palmar surface of the thumb, index, long and radial half of the ring finger. A positive Tinel sign at the median nerve occurs when tapping on it causes the patient to feel tingling or “pins and needles” in the thumb, index and middle fingers. this tingling should duplicate the patient's symptoms at least to a small degree.
Definition of Negative Result
  • A negative Tinel sign at the median nerve means that tapping on it does not cause the patient to feel tingling or “pins and needles” in the thumb, index and middle fingers.
Comments and Pearls
  • There is no standardization for eliciting the Tinel sign.
  • A combination of history, tests/signs and electrodiagnostic testing are be useful for making the diagnosis of CTS and differiating it from other diagnoses in the differential..8
  • There appears to be general consensus that the Tinel sign is not as useful as others in making a differential diagnosis of CTS but it is an appropriate tool in the examination tool box.
  • The wrist should be in a unforced supinated dorsiflexed position while the nerve is taped just proximal to the volar wrist crease. If the patient tenses the wrist then the examinaer will tape the ligment only and not simulate the median nerve apporpriately.
Diagnoses Associated with Tests, Exams and Signs
Video
Tinel Sign Median Exam
Median nerve Tinel's sign is part of the 35 second carpal tunnel syndrome complete exam
YouTube Videos
Carpal Tunnel Syndrome
Tinel's Sign
References
  1. Urbano F. Tinel's sign and Phalen's maneuver: Physical signs of carpal tunnel syndrome. Hosp Phys 2000;36:39-44.
  2. Lifchez SD, Means KR, Jr., Dunn RE, Williams EH, Dellon AL. Intra- and inter-examiner variability in performing Tinel's test. J Hand Surg Am 2010;35:212-6.
  3. Szabo RM, Slater RR, Jr., Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am 1999;24:704-14.
  4. Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity and specificity of clinical testing for carpal tunnel syndrome. Can J Plast Surg 2003;11:70-2.
  5. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther 2004;17:309-19.
  6. LaJoie AS, McCabe SJ, Thomas B, Edgell SE. Determining the sensitivity and specificity of common diagnostic tests for carpal tunnel syndrome using latent class analysis. Plast           Reconstr Surg 2005;116:502-7.
  7. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil 2005;86:609-18.
  8. American Academy of Orthopaedic Surgeons. Clinical Practice Guideline on the Diagnosis of Carpal Tunnel Syndrome. Rosemont, IL2007 May 2007.
  9. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am 2008;33:1518-24.8.