Phalen & Reverse Phalen Test

Phalen Test (wrist flexion sign) is used to evaluate the median nerve compression in the case of Carpal tunnel syndrome. This carpal tunnel test was first described by George S. Phalen, an American orthopedist.

How do you perform the Phalen test?

The Phalen maneuver is done by having the patient drop his or her hands into palmar flexion and then maintain this position for about 1 to 2 minutes. Pressing the dorsal of the hands together increases pressure in the carpal tunnel.

[tele]

What does a positive Phalen Test mean?

The Phalen Test is positive if the patient experiences numbness or tingling throughout the median nerve distribution of the hand within 45 seconds.

Pressing the dorsum of the hands together will often lead to paresthesia in the area supplied by the median nerve in normal patients as well, not just in those with carpal tunnel syndrome.

Patients with carpal tunnel syndrome will experience worsening of symptoms in the Phalen test.

See Also: Carpal tunnel syndrome

What is a Reverse Phalen Test?

A reverse Phalen test (Prayer test) is also used to evaluate the median nerve compression in the case of Carpal tunnel syndrome.

The patient is asked to keep both hands with the wrists in complete extension for 60 seconds (wrist and finger extension). This position increases the pressure in the carpal tunnel. Paresthesia in the region supplied by the median nerve is a sign of carpal tunnel syndrome.

The reverse Phalen test is less reliable than the Phalen test, a study by de Krom and colleagues found the test to have a sensitivity of 41 % and a specificity of 55 %.

In another study, Werner and colleagues showed that Reverse Phalen Test results in a significantly higher intracarpal canal hydrostatic pressure as compared to a traditional Phalen or a modified Phalen maneuver and may add to the sensitivity of conventional screening methods.

Wrist flexion Test

Wrist flexion test is a similar maneuver to phalen test, it’s used to diagnosis the carpal tunnel syndrome as well.

The patient is positioned in sitting with the elbow fully extended, the forearm in supination, and the wrist flexed to 60 degrees. The clinician applies an even constant pressure over the median nerve at the carpal tunnel using the thumb.

A positive test for CTS is the reproduction of symptoms along the median nerve distribution within 30 seconds.

Tetro and colleagues found this test to have a sensitivity of 86 percent and a specificity of 95 percent.

Phalen’s Test Accuracy

The original Phalen test has demonstrated a high sensitivity and a moderate specificity making it moderately acceptable for use in clinical practice:

• Sensitivity: 75%
• Specificity: 47 %

In one study to assess the usefulness of the Phalen test and the Hoffmann Tinel sign in the diagnosis of carpal tunnel syndrome, the sensitivity and specificity of the Phalen test was respectively 85% and 89%, and for the tinel test, 67 and 68%.

Diagnostic Utility of the Phalen Test in Identifying Carpal Tunnel Syndrome:

Population	Reference Standard	Sens	Spec	+LR	-LR
82 patients with suspected cervical radiculopathy or carpal tunnel syndrome	Needle electromyography and nerve conduction studies	.77	.40	1.3	.58
142 patients referred for electrodiagnostic testing	Electrodiagnostic testing	.34	.74	1.31	.89
228 hands referred for electrodiagnostic consultation regarding suspected carpal tunnel syndrome	Nerve conduction studies	.51	.76	2.13	.46
162 hands from 81 patients seeking treatment for carpal tunnel syndrome	Electrodiagnostic testing	.85	.79	4.0	.19
232 patients with carpal tunnel syndrome manifestations and 182 control	Carpal tunnel syndrome diagnosed via clinical examination	.47	.17	0.6	3.12
110 patients referred to laboratory for electrophysiologic examination	Nerve conduction tests	.74	.47	1.4	.55

Notes

Some studies have varied this test to be performed by the patient with wrist in complete flexion and elbow extended, bilateral wrist flexion with the posterior aspect of the hand pressing against one another, or passive wrist flexion by the clinician.

A modified Phalen’s test is done when the examiner applies overpressure during passive wrist flexion and holds the position for 1 minute. Repeat this procedure for the opposite extremity.

The traditional version of this test, in which the patient maximally flexes the wrists by pushing the dorsal aspects of the hands together, is not recommended because the patient may shrug the shoulders, causing compression of the medial branch of the brachial plexus as it passes through the thoracic outlet.

Patients with numbness may not have an exacerbation of symptoms with Phalen’s test, leading to a false-negative result. This test is also frequently positive in those without CTS.

Carpal tunnel syndrome

Carpal tunnel syndrome is a cause of chronic wrist pain and functional impairment of the hand. It results from an ischemic compression of the median nerve at the wrist as it passes through the carpal tunnel.

Compression of the nerve in the carpal tunnel is compounded by an increase in synovial fluid pressure and tendon tension, which decreases the available volume.

The compression of the median nerve may result from a wide variety of factors that compromise the tunnel space such as:

1. Fluid retention, which occurs during pregnancy, Infection and conditions such as renal dysfunction.
2. In addition, several disease conditions, such as gout or pseudogout, acromegaly, or amyotrophy can also decrease the tunnel size.
3. About half of the cases of Carpal tunnel syndrome are related to repetitive and cumulative trauma in the workplace.
4. Forceful and repetitive contraction of the finger flexors can also provoke Carpal tunnel syndrome.
5. Acute wrist trauma has also been associated with Carpal tunnel syndrome.
6. Other causes include collagen disorders, flexor tenosynovitis, diabetes, hypothyroidism, and hemodialysis.
7. Less common causes include instances where the lumbrical muscles encroach within the tunnel during finger movements or become hypertrophied.

Carpal tunnel syndrome more commonly occurs between the fourth and sixth decades.

Carpal tunnel syndrome is the most common compression neuropathy, with a prevalence of 9.2 % in women and 0.6 % in men.

The initial characteristic features of Carpal tunnel syndrome include intermittent pain and paresthesias in the median nerve distribution of the hand which progressively become more persistent as the condition progresses.

Reference

1. Katz JN, Larson MG, Sabra A, et al: The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 112:321–327, 1990. PMID: 2306060
2. de Krom MC, Knipschild PG, Kester AD, et al: Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet 335:393–395, 1990.
3. Werner RA, Bir C, Armstrong TJ: Reverse Phalen’s maneuver as an aid in diagnosing carpal tunnel syndrome. Arch Phys Med Rehabil 75:783–786, 1994.
4. Tetro AM, Evanoff BA, Hollstien SB, et al: A new provocative test for carpal tunnel syndrome. Assessment of wrist flexion and nerve compression. J Bone Joint Surg Br 80:493–498, 1998.
5. Werner RA, Bir C, Armstrong TJ. Reverse Phalen maneuver as an aid in diagnosing carpal tunnel syndrome. Arch Phys Med Rehabil. 1994 Jul;75(7):783-6. PMID: 8024425.
6. Slater RR Jr, Bynum DK: Diagnosis and treatment of carpal tunnel syndrome. Orthop Rev 22:1095–1105, 1993.
7. Gerardi JA, Mack GR, Lutz RB: Acute carpal tunnel syndrome secondary to septic arthritis of the wrist. J Am Osteopath Assoc 89:933–934, 1989.
8. Sawaya RA, Sakr C. When is the Phalen’s test of diagnostic value: an electrophysiologic analysis? J Clin Neurophysiol. 2009 Apr;26(2):132-3. doi: 10.1097/WNP.0b013e31819d8046. PMID: 19279501.
9. Phalen GS: The carpal tunnel syndrome: Clinical evaluation of 598 hands. Clin Orthop 83:29–40, 1972.
10. Phalen GS: Spontaneous compression of the median nerve at the wrist. JAMA 145:1128–1133, 1951.
11. Onieal M-E: Essentials of Musculoskeletal care, 1st ed. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1997.
12. Katz JN, Larson MG, Sabra A, et al: The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 112:321–327, 1990.
13. Brüske J, Bednarski M, Grzelec H, Zyluk A. The usefulness of the Phalen test and the Hoffmann-Tinel sign in the diagnosis of carpal tunnel syndrome. Acta Orthop Belg. 2002 Apr;68(2):141-5. PMID: 12050999.
14. Cunha TAL, Oliveira OM, Ribeiro MB. PHALEN TEST POSITIVATION TIME AND ITS CORRELATION WITH ELECTRONEUROMYOGRAPHY. Acta Ortop Bras. 2020 May-Jun;28(3):114-116. doi: 10.1590/1413-785220202803225744. PMID: 32536790; PMCID: PMC7269134.
15. El Miedany Y, Ashour S, Youssef S, et al. Clinical diagnosis of carpal tunnel syndrome: old tests—new concepts. Joint Bone Spine. 2008;75:451-457.
16. Wainner RS, Fritz JM, Irrgang JJ, et al. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005;86:609-618.
17. Hansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J Phys Med Rehabil. 2004;83: 363-367.
18. xKuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil. 1997;76:451-457.
19. 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: 502-507.
20. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990;112:321-327.
21. MacDermid, JC, and Wessel, J: Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther, 17:309, 2004.
22. Aird, J, et al: The impact of wrist extension provocation on current perception thresholds in patients with carpal tunnel syndrome: a pilot study. J Hand Ther, 19:299, 2006.
23. Clinical Tests for the Musculoskeletal System 3rd Edition.
24. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
25. Sarvdeep S. Dhatt, Sharad Prabhakar – Handbook of Clinical Examination in Orthopedics.