Tinel's Sign: Ulnar Nerve (Elbow)

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 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.

Description

• Positive results are obtained when tapping the ulnar nerve at the medial epicondyle elicits tingling or the feeling of “pins and needles,” particularly in the ring and little fingers.

Pathophysiology

• 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.

Instructions²

• Tap over the ulnar nerve at the spot where it runs under the medial epicondyle

Variations³

• Some examiners find it easier to elicit Tinel's sign over the medial side of the humerus.

Related Signs and Tests^4,5

• Froment sign
• Flexion sign
• Elbow flexion test
• Scratch collapse test

Diagnostic Performance Characteristics⁶

The diagnostic performance of Tinel’s sign has been incompletely studied. Some studies enroll only patients known to have ulnar neuropathy at the elbow, and patients known to be healthy. This design leaves out ambiguous, and other difficult-to-diagnose cases. Hence, studies of this sort overestimate the diagnostic performance of Tinel’s sign.

• One study that appears to have avoided this problem found that the sensitivity (proportion of actual positives that are correctly identified as such) of Tinel’s test for cubital tunnel syndrome was 62% and its specificity (proportion of actual negatives that are correctly identified as such) was 53%.

• When tapping on the ulnar nerve over the cubital tunnel causes the tingling or the feeling of “pins and needles” in the ring and little fingers of the hand.

• A negative Tinel sign at the ulnar nerve in the elbow means that tapping on it does not cause the patient to feel tingling or “pins and needles” in the ring and little fingers.

• There is no standardized procedure for administering the test
• Some advise use of one finger to percuss over the nerve, while others use the blunt end of a neurological hammer or the narrow end of a neurological hammer to tap gently over the nerve. The required number of taps directed to the ulnar nerve at the elbow has been reported by some examiners as two and by others as four to six.

1. Urbano F. Tinel's sign and Phalen's maneuver: Physical signs of carpal tunnel syndrome. Hosp Phys 2000;36:39-44.
2. American Acadamy of Orthopaedic Surgeons. Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome), 2014, available at http://orthoinfo.aaos.org/topic.cfm?topic=a00069.
3. Cutts S. Cubital Tunnel Syndrome. Postgrad Med J. Jan 2007; ;83:28–31.
4. Wojewnik B, Bindra R. Cubital tunnel syndrome – Review of current literature on causes, diagnosis and treatment.J Hand Microsurg 2009:1(2):76–81.
5. 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(9):1518-24.
6. Beekman R, Schreuder AH, Rozeman CA, Koehler PJ, Uitdehaag BM. The diagnostic value of provocative clinical tests in ulnar neuropathy at the elbow is marginal. J Neurol Neurosurg Psychiatry. 2009; 80(12):1369-74.
7. Stuart H. Kuschner, MD; Edward Ebramzadeh, PhD; Susan Mitchell, OTR, CHT Evaluation of Elbow Flexion and Tinel Tests for Cubital Tunnel Syndrome in Asymptomatic Individuals Orthopedics April 2006 - Volume 29 · Issue 4 Available at http://www.healio.com/orthopedics/journals/ortho/2006-4-29-4/%7Bd013c62d-874e-47ac-80b4-aa3329888857%7D/evaluation-of-elbow-flexion-and-tinel-tests-for-cubital-tunnel-syndrome-in-asymptomatic-individuals.