Hoffmann-Tinel sign

Description

Hoffmann-Tinel sign is paresthesia in the distal cutaneous distribution of an injured peripheral nerve evoked by tapping on the nerve more proximally. The sign indicates the compression or regeneration of peripheral nerve fibers.

In modern parlance, the Tinel sign is a provocative test used in suspected cases of entrapment neuropathies affecting either the median nerve within the carpal tunnel or the ulnar nerve in the postcondylar groove. However it is also used in identifying diabetic patients suitable for tibial nerve compression

Jules Tinel (French neurologist) and Paul Hoffmann (German physiologist) both served as physicians on opposite sides of the front line during the First World War and their findings were more than likely independent.

In Anglo-American literature, the term Tinel sign predominates following the translation of his original article by Emanuel B Kaplan in 1972, whilst in German-speaking countries, this test is referred to as the Hoffmann-Tinel sign (Hoffmann-Tinel-Zeichen).

Diagnostic accuracy of the Tinel sign

History

1909 – Wilfred Trotter (1872-1939) and Hugh Morriston Davies (1879-1965) published ‘Experimental studies in the innervation of the skin’. They found that sensations elicited distal to the point of nerve resection are referred to the area or point of nerve resection. they did not relate the experimental studies directly to a test or evaluation in the clinical setting

1915 (March/August) – Paul Hoffmann observed the progress of nerve regeneration by tapping over the affected nerve, proximal to the site of injury/repair or compression. Hoffman described his test in relation to wounded soldiers at Würzburg military installations, in particular 2 cases of patients with radial nerve injury following gun shot wounds to the humerus, under his care in the Medical Policlinic.

Hoffmann described a sign to assess both the success of nerve sutures, and the possible spontaneous recovery of nerve injuries, by lightly percussing with an extended finger in a localized area over the proximal nerve stump or by percussing distally to proximally along the segment of nerve injury or repair.

1915 (October) – Jules Tinel, observed the progress of nerve regeneration after gunshot wounds by applying pressure proximally over the affected nerves. Tinel described “Le signe du Fourmillement” in numerous injured nerves.

1916 – Tinel expounded the theory of his sign with a detailed review of 693 war related peripheral nerve injuries, their assessment and management. He added percussion to the technique of the objective examination of the nerve. Tinel’s descriptions were detailed and insightful. He described not only the regeneration of sensory nerves, but also accurately predicted that tingling was also a sign that motor nerves would regenerate. He separated pain from tingling, and found that the latter had a high prognostic value, and was a sign that the nerve was regenerating. Tinel discovered that if the tingling no longer progressed, that surgical intervention was required as it was a signal of a mechanical obstacle to nerve regeneration.

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]

1946 – Consideration of Tinel as a sign

1950 – George S. Phalen (1911 – 1998) was among the first to apply the “tingling” sign to the diagnosis of carpal tunnel syndrome and gave credit to Tinel (but not Hoffmann) for it.

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 reported a sensitivity of Tinel’s sign of 73% in 452 patients using clinical presentation as the diagnostic standard. Phalen defined a potential diagnostic triad for carpal tunnel syndrome consisting of a positive Tinel sign; a positive wrist-flexion test (Phalen sign) and paresthesias 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 – Durkan’s test – variation of the Hoffman-Tinel sign with improved diagnostic accuracy in the diagnosis of carpal tunnel syndrome.

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 95%; 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. Potentially explains the significant inconsistency in sensitivity and specificity reported for Tinel’s sign.

Associated Persons

• Wilfred Trotter (1872 – 1939)
• Hugh Morriston Davies (1879 – 1965)
• Sir Henry Head (1861 – 1940)
• Paul Hoffmann (1884 – 1962)
• Jules Tinel (1879 – 1952)
• George S. Phalen (1911 – 1998)
• John A Durkan

Alternative names

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

References

• Létiévant E. Traite des sections nerveuses: physiologie pathologique, indications, procedes operatoires. 1873
• Trotter W, Davies HM. Experimental studies in the innervation of the skin. J Physiol. 1909; 38(2-3): 134-246
• 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. [The sign of “tingling” in the lesions of the peripheral nerves] La Presse Médicale. 1915; 47: 388–389. [Tinel sign] [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]
• Napier JR. The significance of Tinel’s sign in peripheral nerve injuries. Brain. 1949;72:63-82.
• Nathan PW, Rennie AM. Value of Tinel’s sign. Lancet. 1946;1(6400):610.
• 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.
• 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.