Tinel Test

Tinel Test is used to evaluate nerve injuries, neuromas, and compression, it’s especially for carpal tunnel syndrome and tarsal tunnel syndrome.

It was named after Jules Tinel (1879–1952), French neurologist,  who published his article in October 1915.

How do you perform the Tinel Test?

In case of carpal tunnel syndrome:

Patient is seated with elbow flexed 30 degrees, forearm supinated, and wrist in neutral position. Examiner allows a reflex hammer (or with two fingers) to fall from a height of 6 inches along median nerve between the tendons at proximal wrist crease.

In case of tarsal tunnel syndrome:

the patient is prone with the knee flexed 90°. The examiner taps the tibial nerve posterior to the medial malleolus with with two fingers or a reflex hammer.

In case of other nerve pathology, the the examiner percusses with two fingers over the affected area of the nerve.

What does a positive Tinel sign mean?

Tinel sign is positive if patient reports paresthesia along the distribution of the tested nerve.

A genuine Tinel’s sign is never considered painful and is due to the growth of touch fibers. If there is pain on tapping, this is not Tinel’s sign but evidence of neuroma or a neuroma-like sign.

Sensitivity & Specificity

• Sensitivity: 70 %
• Specificity: 90 %

Diagnostic Utility of the Tinel Sign in Identifying Carpal Tunnel Syndrome

Population	Reference Standard	Sens	Spec	+LR	-LR
142 patients referred for electrodiagnostic testing	Electrodiagnostic testing	.27	.91	3.0	.80
228 hands referred for electrodiagnostic consultation regarding suspected carpal tunnel syndrome	Nerve conduction studies	.23	.87	1.77	.89
82 patients with suspected cervical radiculopathy or carpal tunnel syndrome	Needle electromyography and nerve conduction studies	.41	.58	.98	1.0
232 patients with carpal tunnel syndrome manifestations and 182 controls	Carpal tunnel syndrome diagnosed via clinical examination	.30	.65	0.9	1.10
110 patients referred to laboratory for electrophysiologic examination	Nerve conduction tests	.60	.67	1.82	.60

Notes

Variations exist between studies on the location and number of taps necessary to elicit a positive response, and in some studies the test is performed by tapping the median nerve in 20 degrees of wrist extension, while others tap along the path of the median nerve up to where the median nerve enters the carpal tunnel.

The Tinel sign is elicitable after about 4–6 weeks following a peripheral nerve injury and is described as perceiving mild electric current/pins and needles/hyperesthesia referred to the cutaneous distribution of the nerve. It should be kept in mind that the tingling of regeneration of touch fibers is barely perceived in the area of percussion and radiates only into the cutaneous distribution of the specific nerve.

Advancing Tinel’s sign can be used to calculate and gauge progression of recovery (spontaneous or following repair):

• Non-progressing Tinel’s indicates interruption of nerve regeneration.
• Static Tinel’s at injury site and one present distally also indicates poor prognosis.
• Advancing Tinel’s seen only in grades II and III. (IV and V grades show it only after repair).

The examiner percusses distal to proximal along the nerve route to elicit this test. The sequential recording of Tinel’s sign can corroborate with nerve regeneration. If the sign remains fixed in one spot for several consecutive weeks or even months, there may be an obstacle, and they may be grouped together, forming a neuroma. If the location of the sign moves progressively in a distal direction, this is a favorable sign.

The sign can be elicited by gentle tapping with the eraser on the end of a pencil to avoid widespread mechanical stimulus over the involved nerve trunk or branches of the nerve distal to the site of injury or tapping over the belly of the muscle innervated by the nerve.

Tinel’s sign cannot be elicited in patients with a nerve-root lesion proximal to the dorsal root ganglion because the sensitive touch fibers that are healing are proximal to the ganglion under these circumstances.

Reference

1. Tinel, J. (1978) The “tingling sign” in peripheral nerve lesions (Translated by EB Kaplan). In: M. Spinner M (Ed.), Injuries to the Ma jor Branches of Peripheral Nerves of the Forearm. (2nd ed.) (pp 8–13). Philadelphia: WD Saunders Co
2. Chin-Wei Liu, Tien-Wen Chen, Ming-Cheng Wang, Chia-Hsin Chen, Chia-Ling Lee, Mao-Hsiung Huang: Relationship between carpal tunnel syndrome and wrist angle in computer workers. Kaohsiung J Med Sci. 2003 Dec;19(12):617-23. doi: 10.1016/S1607-551X(09)70515-7. PMID: 14719559
3. 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.
4. Kuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil. 1997;76:451-457
5. 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.
6. 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.
7. Clinical Tests for the Musculoskeletal System 3rd Edition.
8. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.