Hoffmann-Tinel sign

The sign is most commonly called Tinel sign, especially in modern English-language clinical teaching. The historically fuller term Hoffmann–Tinel sign is preferable when discussing the original 1915 descriptions, as Paul Hoffmann and Jules Tinel independently described the phenomenon during the First World War. Hoffmann described a method based chiefly on light percussion of the regenerating nerve, while Tinel described pressure over the injured nerve trunk producing distal formication.

A positive sign requires radiating tingling, pins-and-needles, or electric-like paraesthesia in the cutaneous territory of the nerve being examined. Local tenderness, local pain, or the patient simply saying “I feel that” is not a positive test. In regenerating nerves, the most useful finding is not the presence of tingling alone, but whether the point of elicited paraesthesia progresses distally over time.

Hoffmann–Tinel test variants

The modern “Tinel sign” is not a single standardised manoeuvre. Historical descriptions and modern clinical practice include pressure, percussion, tapping, repeated tapping, and preload techniques.

Term	Method	Comment
Hoffmann sign 1915	Light percussion with the examiner’s extended finger over the regenerating or injured nerve	Closest to most modern “tap over the nerve” descriptions. Hoffmann emphasised that only light percussive pressure should be applied.
Tinel sign 1915	Pressure over the injured nerve trunk. Percussion if callus present.	Tinel distinguished distal formication from local pain and used distal progression to assess regeneration.
Modern Tinel test in CTS 1950	Tapping or percussion over the median nerve at the wrist	The “Tinel sign,” but performed as Hoffmann’s light percussion method rather than Tinel’s original pressure description.

Modern textbook and journal article descriptions vary widely. Examples include gentle tapping with a finger, two-finger tapping, percussion with a tendon hammer, tapping with a pencil eraser, or pressure before percussion. Few studies specify the force used. This lack of standardisation possibly contributes to the wide range of reported sensitivity and specificity. Lifchez et al. demonstrated substantial intra- and inter-examiner variability when clinicians performed single-finger strike, double-finger strike, and preload Tinel-type techniques.

How to perform in suspected carpal tunnel syndrome

For suspected carpal tunnel syndrome, the Hoffmann–Tinel sign should be elicited by light percussion over the median nerve at the wrist, usually at or just proximal to the distal wrist crease over the proximal carpal tunnel. The forearm should be supinated and relaxed, with the wrist neutral or only slightly extended.

A positive test is reproduction of the patient’s characteristic tingling, pins-and-needles, or electric-like paraesthesia into the median nerve distribution to the thumb, index finger, middle finger, and radial half of the ring finger. Local wrist discomfort alone is negative.

The technique should be recorded precisely e.g.

Finger-percussion Tinel sign over the median nerve at the distal wrist crease: positive/negative.

If a tendon hammer, pencil eraser, repeated tapping, thumb preload, or sustained pressure is used, this should be stated, because these are not equivalent manoeuvres.

Diagnostic accuracy in carpal tunnel syndrome

The Tinel or Hoffmann–Tinel sign is quick, anatomically useful, and historically important but has limited standalone diagnostic value for carpal tunnel syndrome. Reported accuracy varies because of differences in technique, force, reference standard, disease severity, and patient selection.

Reported sensitivities range from very low to moderate, while specificity is often higher but inconsistent. Heller et al. reported sensitivity 60% and specificity 77% against EMG criteria; Buch-Jaeger and Foucher reported sensitivity 42% and specificity 64% using nerve conduction studies; Durkan reported sensitivity 56% and specificity 80% for gentle median nerve percussion; and Kuhlman and Hennessey reported sensitivity 23% and specificity 87%.

Study	How Tinel was performed	Sensitivity	Specificity	Comment
Phalen 1966 Clinical CTS series	Light percussion over median nerve at wrist	73%	N/A	Case series, no control group.
Heller 1986 80 hands EMG reference	Percussion of the nerve near the lesion	60%	77%	Combination of both positive increased specificity to 91% but reduced sensitivity to 47%.
Durkan 1991 46 CTS hands 50 controls Electrodiagnostic reference	Gentle percussion of median nerve at wrist	56%	80%	Tinel less sensitive than Phalen and carpal compression
Buch-Jaeger 1994 172 hands Nerve conduction reference	Manual percussion of volar surface of wrist	42%	64%	Authors considered individual clinical tests unreliable for confirming CTS pre-operatively.
Kuhlman 1997 228 hands Electrodiagnostic reference	Gentle tapping with finger, repeated for consistency	23%	87%	Very low sensitivity but relatively high specificity
Almasi-Doghaee 2016 89 patients Electrodiagnostic reference	Not specified	65.3%	47.1%	Carpal compression outperformed Tinel and Phalen

Bottom line: the Hoffmann–Tinel sign is best interpreted as an adjunctive anatomical sign. A positive result supports focal nerve mechanosensitivity when it reproduces radiating paraesthesia in the correct nerve distribution. A negative result does not exclude carpal tunnel syndrome, particularly in mild disease, advanced axonal loss, or when the technique is poorly standardised.

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History of the Hoffmann-Tinel sign

1873 – Jean-Joseph Émile Létiévant published Traite des sections nerveuses, a 548-page treatise on nerve section, nerve injury, neurotomy and sensory recovery. He provided early descriptions of esthesiography, protopathic sensibility, and the “tingling sign” in peripheral nerve lesions. In cases of median nerve injury, Létiévant observed that pressure over the nerve at the repair site, or distal to it, could produce painful tingling in the fingers. However, he interpreted the phenomenon within his theory of motor and sensory substitution, rather than as a specific sign of axonal regeneration.

1905 – Sir Henry Head along with William Halse Rivers, and James Sherren published The afferent nervous system from a new aspect. They described abnormal referred sensory phenomena during recovery after nerve injury, including widespread formication radiating over affected areas.

1909 – Wilfred Trotter and Hugh Morriston Davies published Experimental studies in the innervation of the skin. They experimentally divided cutaneous nerves in themselves and studied sensory loss and recovery in detail. Their work described peripheral reference as abnormal sensations elicited from recovering areas or injured nerves that could be referred distally to the cutaneous territory of the nerve. They noted that stimulation below the point of section was much more sensitive and could produce peripherally referred sensations of touch, pain, and cold.

1915, March 28 – Paul Hoffmann published Über eine Methode, den Erfolg einer Nervennaht zu beurteilen based on wounded soldiers treated in Würzburg. He described a method for assessing whether regenerating fibres had crossed a nerve suture before motor recovery was clinically evident. In a radial nerve injury, pressure over the regenerating nerve produced a prickling sensation referred into the anaesthetic radial distribution of the hand. Recovery of hand extension followed four weeks later.

1915, August 1 – Hoffmann published a second paper, Weiteres über das Verhalten frisch regenerierter Nerven und über eine Methode of his refined method. He emphasised that newly regenerating fibres were mechanically hyperexcitable and that the sensation was best elicited by light percussion with the examiner’s extended finger, not by forceful pressure.

1915, October 7 – Jules Tinel (1879–1952) independently published Le signe du ‘fourmillement’ dans les lésions des nerfs périphériques. Tinel described pressure over an injured nerve trunk producing tingling referred distally into the nerve’s cutaneous territory. He distinguished this non-painful “formication” of regeneration from local neuritic pain.

1916 – Tinel published Les blessures des nerfs, his monograph on war-related peripheral nerve injuries. He described records 628 peripheral nerve injuries (409 upper-limb and 219 lower-limb), with radial nerve injuries the largest subgroup. He added percussion to the technique of the objective examination of the nerve.

Formication provoked by pressure. When compression or percussion is lightly applied to the injured nerve trunk, we often find, in the cutaneous region of the nerve, a creeping sensation usually compared by the patient to that caused by electricity. This formication is quite distinct from the pain on pressure, which exists in nerve irritations.

Tinel 1916: 34 [English translation 1918: 34]

1919–1944 – The sign’s reputation became controversial. Elsberg questioned whether a positive sign reliably indicated nerve continuity. Lewis J. Pollock and Loyal Davis found it absent in some recovering nerves and present in many complete interruptions. Seddon et al considered it irregular as a guide to regeneration rate, and Coleman criticised over-reliance on it after patients with positive signs were found at operation to have separated bulbous nerve ends.

1946 – Peter Wilfred Nathan published Value of Tinel’s sign in The Lancet, based on 93 peripheral nerve lesions seen at a military peripheral nerve injury centre. They noted that the sign had fallen into neglect, and argued its clinical value when interpreted cautiously.

1949 – John Russell Napier published The significance of Tinel’s sign in peripheral nerve injuries. Napier reframed the sign as evidence of mechanically hyperexcitable sensory fibres, not automatic proof of useful functional recovery. He concluded that a positive sign below the lesion indicates regenerating axis cylinders, but by itself does not prove nerve continuity. A steadily progressive sign strongly suggests continuity, whereas a non-progressive sign suggests complete interruption or mechanical obstruction.

1950 – George S. Phalen et al published Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. They reported three cases of spontaneous median nerve compression at the wrist and identified a positive Tinel sign over the median nerve at the wrist, together with sensory loss limited to the distal median distribution, as key clinical findings. This shifted the sign as a test of nerve regeneration after trauma to a provocative sign for entrapment neuropathy. Interestingly he credited Tinel but not Hoffmann with the sign and provided no further description of the sign.

The presence of a positive Tinel sign over the median nerve at the wrist, as well as the strict limitation of all sensory findings to the median distribution, distal to the wrist, are the two most reliable diagnostic findings.

Phalen 1950: 112

1966 – Phalen published The carpal-tunnel syndrome and reported Tinel sign findings in 452 hands. He defined a potential diagnostic triad for carpal tunnel syndrome consisting of a positive Tinel sign; a positive wrist-flexion test (Phalen sign) and paresthesia within the median nerve distribution

Tinel’s sign, a tingling sensation radiating out into the hand produced by light percussion over the median nerve at the wrist, is a valuable sign in the diagnosis of carpal-tunnel syndrome. In 452 (73 per cent) of the hands in this series Tinel’s sign was present; in 169 it was absent ; in thirty-three there was no note regarding Tinel’s sign.

Phalen 1966: 214

1991 – John A. Durkan introduced the carpal compression test as a separate provocative manoeuvre using sustained direct pressure over the carpal tunnel. It should not be described as a variation of the Hoffmann–Tinel sign.

1993 – Buck-Gramcko and Lubahn published English translations of Hoffmann’s 1915 papers and argued that the well-known Tinel sign should more properly be called The Hoffmann-Tinel sign, as Hoffmann’s first report preceded Tinel’s by several months.

2004 – Lee and Dellon reported that a positive Tinel sign is a reliable indicator of successful outcome from decompression of the tibial nerve in patients with diabetes with symptomatic neuropathy, and in patients with symptomatic idiopathic neuropathy. Identified patients with diabetic symptomatic neuropathy (sensitivity 88%; specificity 50%; PPV 88%) and idiopathic symptomatic neuropathy (sensitivity 95%; specificity 56%; PPV 93%) who would benefit from tibial nerve decompression.

2010 – Lifchez et al demonstrated considerable intra- and inter-examiner differences in the range of forces generated by the different Tinel’s techniques that are used in clinical practice.

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Associated Persons

• Jean-Joseph Émile Létiévant (1830–1884)
• Wilfred Trotter (1872-1939)
• Hugh Morriston Davies (1879-1965)
• Sir Henry Head (1861-1940)
• James Sherren (1872-1945)
• William Halse Rivers Rivers (1864-1922)
• Paul Hoffmann (1884-1962)
• Jules Tinel (1879-1952)
• Peter Wilfred Nathan (1914–2002)
• John Russell Napier (1917-1987)
• George S. Phalen (1911-1998)
• John A Durkan

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Alternative names

• Hoffmann-Tinel sign
• Hoffmann sign, Hoffmann’s sign
• Tinel sign, Tinel’s sign

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References

Historic references

• Létiévant E. Traite des sections nerveuses: physiologie pathologique, indications, procedes operatoires. 1873
• Head H, Rivers WHR, Sherren J. The afferent nervous system from a new aspect. Brain. 1905; 28: 99–115.
• Trotter W, Davies HM. Experimental studies in the innervation of the skin. J Physiol. 1909; 38(2-3): 134-246
• Trotter W, Davies HM. The peculiarities of sensibility found in cutaneous areas supplied by regenerating nerves. Journal für Psychologie und Neurologie 1913; 20: 102-150
• Hoffmann P. Über eine Methode, den Erfolg einer Nervennaht zu beurteilen. [Using a method to assess the success of a nerve attack] Medizinische Klinik, 1915; 11: 359-360
• Hoffmann P. Weiteres über das Verhalten frisch regenerierter Nerven und über eine Methode, den Erfolg einer Nervennaht frühzeitig zu beurteilen. Medizinische Klinik. 1915; 11: 856-858.
• Tinel J. Le signe du ‘fourmillement’ dans les lésions des nerfs périphériques. La Presse Médicale. 1915; 47: 388–389. [English translation: Kaplan EB The “tingling” sign in peripheral nerve lesions. In: Spinner M, ed. Injuries to the Major Branches of Peripheral Nerves in the Forearm. Philadelphia: Saunders; 1972:8-13.[PDF]]
• Tinel J. Les blessures des nerfs : sémiologie des lésions nerveuses périphériques par blessures de guerre [English translation: Joll CA. Nerve wounds, symptomatology of peripheral nerve lesions caused by war wounds. 1918. London, Baillière]

Eponymous term review

• Stookey B. The limitations of Tinel’s sign in peripheral nerve injuries. Neurological Bulletin. 1919;2:380–384.
• Elsberg CA, Woods AH. Problems in the diagnosis and treatment of injuries to the peripheral nerves: the outlook for the future. Archives of Neurology & Psychiatry. 1919;2(6):645–666.
• Pollock LJ, Davis L. Peripheral nerve injuries. Am. J. Surg. 1932; 15: 179-634.
• Seddon HJ, Medawar PB, Smith H. Rate of regeneration of peripheral nerves in man. J Physiol. 1943 Sep 30;102(2):191-215. 
• Coleman CC. Peripheral nerve surgery—diagnostic considerations. Journal of Neurosurgery. 1944;1(2):123–132.
• Nathan PW, Rennie AM. Value of Tinel’s sign. Lancet. 1946;1(6400):610.
• Napier JR. The significance of Tinel’s sign in peripheral nerve injuries. Brain. 1949;72:63-82.
• Phalen GS, Gardner WJ, Londe AA. Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. J Bone Joint Surg Am. 1950; 32A(1): 109-12.
• Phalen GS. The carpal-tunnel syndrome. Seventeen years’ experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am. 1966;48(2):211-228.
• Sunderland S. The nerve lesion in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1976;39(7):615-626.
• Heller L, Ring H, Costeff H, Solzi P. Evaluation of Tinel’s and Phalen’s signs in diagnosis of the carpal tunnel syndrome. Eur Neurol. 1986; 25(1):40-2.
• Durkan JA. A new diagnostic test for carpal tunnel syndrome. J Bone Joint Surg Am. 1991; 73(4): 535-8.
• Hoffmann P, Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. 1915. J Hand Surg Br. 1993; 18(6): 800-5
• Buch-Jaeger N, Foucher G. Correlation of clinical signs with nerve conduction tests in the diagnosis of carpal tunnel syndrome. J Hand Surg Br. 1994; 19(6): 720-4.
• Kuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil. 1997 Nov-Dec;76(6):451-7.
• Alfonso MI, Dzwierzynski W. Hoffman-Tinel sign. The realities. Phys Med Rehabil Clin N Am. 1998; 9(4): 721-v.
• D’Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000;283(23):3110-3117.
• Koehler PJ, Bruyn GW, Pearce JMS. The Hoffmann-Tinel Sign. Neurological Eponyms. Oxford University Press 2000. pp136-143
• Davis EN, Chung KC. The Tinel sign: a historical perspective. Plast Reconstr Surg. 2004; 114(2): 494-9.
• Lee CH, Dellon AL. Prognostic ability of Tinel sign in determining outcome for decompression surgery in diabetic and nondiabetic neuropathy. Ann Plast Surg. 2004;53(6):523-527.
• Sansone JM, Gatzke AM, Aslinia F, Rolak LA, Yale SH. Jules Tinel (1879–1952) and Paul Hoffmann (1884–1962). Clin Med Res. 2006; 4(1): 85–89.
• Lifchez SD, Means KR Jr, Dunn RE, Williams EH, Dellon AL. Intra- and inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010; 35(2): 212-216.
• Almasi-Doghaee M, Boostani R, Saeedi M, Ebrahimzadeh S, Moghadam-Ahmadi A, Saeedi-Borujeni MJ. Carpal compression, Phalen’s and Tinel’s test: Which one is more suitable for carpal tunnel syndrome? Iran J Neurol. 2016 Jul 6;15(3):173-4.
• Turgut AÇ, Tubbs RS, Turgut M. Paul Hoffmann (1884-1962 AD) and Jules Tinel (1879-1952 AD), and their legacy to neuroscience: the Hoffmann-Tinel sign. Childs Nerv Syst. 2019 May;35(5):733-734.
• Cadogan O. Clinical Signs in Carpal Tunnel Syndrome. LITFL
• Carpal Tunnel Exam. Stanford Medicine 25