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Exams and Signs

Historical Overview1

  • 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 tapped 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.

Description1-6

  • When the area over a nerve is lightly tapped, the patient may feel a tingling sensation or “pins and needles” in the area served by it. Tinel’s sign may be elicited when a mass is compressing a nerve. A variety of non-malignant and malignant masses can cause Tinel’s sign to be elicited, including but not limited to, neurilemmomas (Schwannomas) that compresses the median nerve at the wrist, the radial or ulnar nerves, the anterior interosseous nerve, the muscle-cutaneous nerve, and the digital nerves. Tinel’s sign can also be elicited by the presence of a ganglion cyst, and such cases affecting the median nerve in the carpal tunnel and the radial and ulnar nerves have been reported.
  • Where Tinel’s sign appears depends on which nerve is compressed and where it is compressed:
    • Median nerve at the carpal tunnel: thumb, index and middle finger
    • Radial nerve at the wrist: radial, back side of the hand
    • Superficial radial nerve in the forearm: pain or dysesthesias on the dorsal radial forearm radiating to the thumb and index finger (with variations in distribution owing to differences in anatomical phenotypes
    • Ulnar nerve at the wrist: numbness and tingling in the little finger and along the outside of the ring finger
    • Ulnar nerve at the elbow: tingling in the forearm, ulnar-palmar side of the wrist and hand, and in little finger and the ring finger

Pathophysiology

  • Due to nerve compression
  • On a cellular level, the sign may be caused by a hyper-excitable membrane.

Instructions1,7

  • When a palpable mass is present, the nerve is often tapped at this site.
  • For suspected compression of the median nerve in the carpal tunnel, tap over it as it passes through this tunnel in the wrist.
  • For suspected compression of ulnar nerve in the cubital tunnel, tap over the nerve in the cubital tunnel in the elbow.
  • For suspected compression of the superficial radial nerve, Tinel’s sign can be elicited by tapping over the course of the nerve.
  • The intensity of the tapping should be enough to cause the expected response while avoiding direct mechanical stimulation of the nerve.

Variations8

  • 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

  • Related signs and tests will depend on which nerve is compressed, and where it is compressed.
  • Imaging is often used in patients with a suspected (or palpable) mass. The modality that is most informative depends on the type of mass:
    • For ganglion cysts, plain X-rays are, if needed, often sufficient
    • MRI is often used for more suspicious masses

Diagnostic Performance Characteristics

  • Whether Tinel’s sign can be elicited due to the presence of a mass partly depends on the location and size of the mass. Because these vary in clinical practice, it is difficult to derive a quantitative estimate of the diagnostic performance of this sign that is clinically relevant. One study2 of 234 solitary neurilemmomas found that Tinel’s sign was present in 81% of patients.
Definition of Positive Result
  • When tapping on the nerve that is the origin of the mass or is compressed by a mass, the patient experiences paresthesias in all or part of the nerve’s distribution.
Definition of Negative Result
  • A negative Tinel sign when tapping on a mass means that a nerve is unlikely to be compressed by the mass and/or that the mass is less likely to be of neural origin.  Therefore tapping on the mass does not cause the patient to feel tingling or “pins and needles” at or distal to the mass.
Comments and Pearls
  • The methods used to elicit Tinel’s sign are not standardized but can still be useful when identifying tumors of neural origin.
Diagnoses Associated with Exams and Signs
References
  1. Urbano F. Tinel's sign and Phalen's maneuver: Physical signs of carpal tunnel syndrome. Hosp Phys 2000;36:39-44.
  2. Knight DMA, Birch R, Pringle J. Benign Solatary Schwannomas. J Bone Joint Surg Br 2007;89:382-7.
  3. Adani R, et al. Schwannomas of the upper extremity: analysis of 34 cases. Acta Neurochir (Wien) 2014;156:2325-30.
  4. Yalcinkaya M, Akman YE, Bagatur AE. Unilateral carpal tunnel syndrome caused by an occult ganglion in the carpal tunnel: a report of two cases. Case Rep Orthop 2014 ePub.
  5. Sharma RR, et al. Symptomatic epineural ganglion cyst of the ulnar nerve in the cubital tunnel: a case report and brief review of the literature. J Clin Neurosci. 2000;7:542-3.
  6. McFarlane J, et al. A ganglion cyst at the elbow causing superficial radial nerve compression: a case report. J Med Case Rep 2008;2:122-4.
  7. Dang AC, Rodner CM. Unusual compression neuropathies of the forearm, Part I: radial nerve. J Hand Surg Am 2009;34:1906-1914.
  8. Lifchez SD, et al. Intra- and inter-examiner variability in performing Tinel's test. J Hand Surg Am 2010;35:212-6
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