Tinel's Sign
Patient: wrist in neutral position, forearm supinated.
Examiner: taps over the carpal tunnel.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
Numbness or tingling within the median nerve distribution or an electric shock sensation radiating into the hand are considered positive test results. From this positive finding the examiner can make the inference that the median nerve is compressed. It should be noted that this provocative test has poor sensitivity (23-60%)1 and only fair specificity (64-87%)1. Furthermore, Tinel's sign has been shown to be present in up to 40% of people without CTS1. Therefore results of this test may be used judiciously.
Phalen's Sign
Patient: place the dorsum of the hands together to maximally flex the wrists. Gently push the wrists together and hold for 1 minute.
Examiner: Ensure the patient does not shrug their shoulders during the test. Alternatively, the examiner may apply overpressure during passive wrist flexion and hold for 1 minute.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
Numbness or tingling along a specific nerve distribution pattern, median or ulnar nerves being the most common, is a positive test. In the case of CTS the tingling paraesthesias should be consistent with a median nerve distribution, from which it can be inferred from the examiner that the median nerve is compressed. However, this provocative test may be used judiciously due to the extermely variable sensitivity (10-90%)1 and specificity (33-86%)1.
Allen Test
Patient: quickly opens and closes the hand several times and then makes a tight fist. Once the examiner has compressed the arteries, the patient opens her hand, it should appear blanched.
Examiner: places thumb and index finger over the radial and ulnar arteries and compresses them. One artery is released at a time to see if the hand flushes. Bilateral comparison determines the effectiveness of the arteries.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
The hand should blanch white following compression of both arteries. After releasing either artery the hand normally flushes as blood flow is re-established. A positive Allen test therefore is one where the hand does not flush within approximately 7 seconds. The inference made is that the artery that is released is insufficient since it fails to supply the hand with the other artery compressed. This provocative test may be considered since it has good sensitivity (73%)2 and excellent specificity (97%)2.
Hand Elevation Test
Patient: holds their hand(s) above their head.
Examiner: times 1 minute.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
Numbness and tingling along the median nerve distribution is a positive finding. The examiner can infer that the median nerve is compressed. Results of this test may be considered in the diagnosis of CTS since it has good sensitivity (88%)1 and excellent specificity (99%)1.
Pressure Provocation Test
Patient: wrist in neutral position, forearm supinated.
Examiner: exerts even pressure with both thumbs directly over the carpal tunnel and holds for at least 30 seconds.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
A positive test is numbness or tingling into the palmar aspect of the thumb, index, and middle fingers, which is inferred by the examiner to mean median nerve compression. This provocative test may not be used, due to variable sensitivity (28-63%)1 and specificity (33-74%)1.
Finkelstein Test
Patient: makes a fist with the thumb inside the fingers.
Examiner: stabilizes the forearm while pressing on the radial styloid process and ulnarly deviates the wrist.
Image Source: Victoria Squissato
Image Source: Victoria Squissato
Pain over the radial styloid and/or over the abductor pollicis longus and extensor pollicis brevis tendons represent a positive finding. A positive Finkelstein test has long been considered pathognomonic for De Quervain’s Tenosynovitis3. However, it should be noted that the test is usually uncomfortable even for healthy individuals, therefore it is always important to compare wrists. Studies have shown that it has good sensitivity and specificity3.
Flick Maneuver
Examiner: asks the patient she does with her hands and wrists when her symptoms are most severe.
Patient: answer question verbally or demonstrates movement.
A positive response is a description and/or demonstration of a flicking motion of the hands and wrists. From this it may be inferred that the patient has CTS. The flick maneuver looked very promising in an early study which documented a sensitivity of 93% and a specificity of 96%4. However a more recent study found the flick maneuver to have much more variable sensitivity (27–46%)5 and specificity (62–87%)5 so the diagnostic value of this test may be dubious.
1Kleopa KA, Bird SJ. 2011. ACP PIER & AHFS DI Essentials. Philadelphia, PA. American College of Physicians. STAT!Ref Online Electronic Medical Library. http://online.statref.com.proxy.queensu.ca/document.aspx?fxid=92&docid=803. Accessed 6/15/2011.
2Kohonen M, Teerenhovi O, Terho T, Laurikka J, Tarkka M. Is the Allen test reliable enough? European Journal of Cardio-thoracic Surgery. 2001:32;902-905.
3Dawson C, Mudgal CS. Staged Description of the Finkelstein Test. Journal of Hand Surgery. 2010;35A:1513–1515.
4Pryse-Phillips W. Validation of a diagnostic sign in carpal tunnel syndrome. Journal of Neurology, Neurosurgery & Psychiatry. 1984;47:870–2.
5Hansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. American Journal of Physical Medicine Rehabilitation. 2004;83:363–367.
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