Tinel's Sign Research Articles

Macrovascular decompression of the median nerve for posttraumatic neuralgic limb pain

Neuropathic pain is rare in children, and few reports provide adequate guidelines for treatment. The authors describe the successful treatment of tardy neuropathic pain via macrovascular decompression in a 15-year-old boy who presented with progressive pain 11 years following trauma to the upper extremity that had required surgical repair of the brachial artery. Examination revealed mild chronic median and ulnar motor neuropathy as well as recent progressive lancinating pain and a Tinel sign at the prior scar. A soft tissue mass in the neurovascular bundle at the site of previous injury was noted on MRI. Surgical exploration demonstrated an altered anatomical relationship of the previously repaired brachial artery and the median nerve, resulting in pulsatile compression of the median nerve by the brachial artery. Neurolysis and decompression of the median nerve with physical separation from the brachial artery resulted in immediate pain relief. This is the first report of macrovascular decompression of a major peripheral nerve with complete symptom resolution. Noninvasive imaging together with a thorough history and physical examination can support identification of this potential etiology of peripheral neuralgic pain. Recognition and treatment of this uncommon problem may yield improved outcomes for children with neuropathic pain.

The Positive Effect of Neurolysis on Diabetic Patients with Compressed Nerves of the Lower Extremities: A Systematic Review and Meta-analysis.

Background:Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial.Methods:A search of ClinicalTrials.gov and Cochrane clinical trials registries, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, SCOPUS, and Google Scholar from 1962 to 2012, yielded 1956 citations. Any potential randomized or quasi-randomized controlled trials and observational cohort studies of diabetics with neurolysis of the common peroneal nerve, deep peroneal nerve, or tibial nerve were assessed. We included articles in any language that 1) provided information about diabetic patients who had neurolysis for symptomatic nerve compression diagnosed by (+) Tinel sign or electrodiagnostic study, and 2) quantified outcomes for pain, sensibility, or ulcerations/amputations. Case reports, review articles, animal or cadaver studies, and studies with <10 patients were excluded. We assessed pain relief, recovery of sensibility, and postoperative incidence of ulcerations/amputations at follow-up >3 months. A meta-analysis of descriptive statistics was performed.Results:Ten clinical series with a mean clinical relevance score of 70% and a mean methodologic quality score of 50% met inclusion criteria. We included 875 diabetic patients and 1053 LEs. Pain relief >3 points on visual analog scale occurred in 91% of patients; sensibility improved in 69%. Postoperative ulceration/amputation incidence was significantly reduced compared to preoperative incidence (odds ratio = 0.066, 95% confidence interval = 0.026–0.164, P < 0.0001).Conclusions:Observational data suggest that neurolysis significantly improves outcomes for diabetic patients with compressed nerves of the LE. No randomized controlled trials have been published.

Chiropractic management of a patient with ulnar nerve compression symptoms: a case report

ObjectiveThe purpose of this case report is to describe chiropractic management of a patient with arm and hand numbness and who was suspected to have ulnar nerve compression. Clinical FeaturesA 41-year-old woman presented with hand weakness and numbness along the medial aspect of her right forearm and the 3 most medial fingers. The onset of symptoms presented suddenly, 3 weeks prior, when she woke up in the morning and assumed she had “slept wrong.” The patient’s posture showed protracted shoulders and moderate forward head carriage. Orthopedic assessment revealed symptomatic right elevated arm stress test, grip strength asymmetry, and a Tinel sign at the right cubital tunnel. Intervention and OutcomeThe patient was treated using chiropractic care, which consisted of manipulative therapy, myofascial therapy, and elastic therapeutic taping. Active home care included performing postural exercises and education about workstation ergonomics. She demonstrated immediate subjective improvement of her numbness and weakness after the first treatment. Over a series of 11 treatments, her symptoms resolved completely; and she was able to perform work tasks without dysfunction. ConclusionChiropractic treatment consisting of manipulation, soft tissue mobilizations, exercise, and education of workstation ergonomics appeared to reduce the symptoms of ulnar nerve compression symptoms for this patient.

Surgery of tarsal tunnel: a report about four cases

The tarsal tunnel syndrome is a rare disease. These symptoms include pain and plantar dysesthesia in the territory of the posterior tibial nerve. Existence of a Tinel sign on the path of the posterior tibial nerve is the best argument in favour of clinical compression. The electrophysiological study confirmed the diagnosis in the four cases. Imaging can help the etiological analysis looking for a lesion of the bone structure, the sequelae of fracture of the hindfoot, static disorders of the foot and the presence of any space-occupying intraductal lesions. Initial treatment is always medical; it combines analgesic and anti-inflammatory prescriptions. Sensory-motor rehabilitation is always indicated. The apparatus is indicated in case of static disorders of the foot. Surgery is indicated if conservative treatment fails or if there is a presence of a compressive lesion. It is based on the incision of the flexor retinaculum, the opening of the abductor hallucis muscle fascia and the tibial nerve neurolysis. The surgery must release all these structures to have good results and avoid recurrences in the long run.

Bilateral Transfemoral Lower Extremity Transplantation: Result at 1 Year

Upper limb transplantation has become a treatment option for upper limb amputees with good midterm results. Lower extremity transplantation has never been considered for fear of poor results. The authors present a bilateral transfemoral transplantation of lower extremities performed to a 22-year patient at 12 months of follow-up. The donor was a full HLA-mismatched female multiorgan donor. CMV status was D-/R-. A primary CMV infection coincident with an acute rejection occurred at 3 months and responded to treatment. At 1 year, the Tinel's sign is at malleolar level, there is active knee extension and active plantar flexion of the foot. The patient is walking between parallel bars. Further substantial improvements are expected with longer rehabilitation and follow-up.

Hand and Upper Extremity Function in Workers With Hand Dermatitis

Traditional methods of assessing impairment associated with skin conditions focus on clinical severity, medication usage, activities of daily living, and quality of life. Assessment of function and ability to work may provide important additional information when determining readiness to work. The objective was to gain an understanding of the functional impairment of the hand and upper extremity associated with hand dermatitis and the impact of hand dermatitis on quality of life, work instability, and productivity. Sixty-two patients with suspected contact dermatitis of the hands participated in physical and functional assessments of the upper extremity and patient-reported questionnaires including Dermatology Life Quality Index, Short Form 36 Health Survey, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Work Instability Scale, and Work Limitations Questionnaire. Numbness and finger joint restrictions were moderate to severe in 29% and 30% of the workers, respectively. Positive Tinel and/or Phalen signs occurred in 25%. Forty-eight percent reported moderate-to-high work instability, and 31% reported a greater than 10% decrease in work productivity. Thirty-five percent missed work in the past year, 19% were doing a different job, and 9% were not working. Patients with hand dermatitis demonstrate significant functional compromise of the hand and a decrease in ability to work.

Nerve Stripper-Assisted Sural Nerve Harvest

Sural nerve has the favorite length and size for nerve graft interposition. Here two techniques, that is, "stocking seam" and "stair-step" or "stepladder," have been used for harvesting sural nerve. The first technique results in an unsightly scar at the posterior calf, and the latter one takes a long time to perform and exert undue traction to the graft during harvesting. The purpose of this article is to describe our experience in harvesting the sural nerve by a nerve stripper. A nerve stripper was used for harvesting sural nerve in 35 adult patients (in 6 patients, sural harvesting was done bilaterally), 27 men and 8 women. Thirty-one sural nerve harvests were done by closed technique (i.e., harvesting of sural nerve only by two incisions, one in the posterior of the lateral malleolus and the other in popliteal fossa), in 8 others by limited open technique, and in 2 cases, there was early laceration of the sural nerve at the beginning of the study. The contralateral sural nerve was harvested in one patient and medial antebrachial nerve in another by open technique. The mean length of the retrieved sural nerve was 34.5 cm in the closed technique group and 35 cm in the limited open technique group. We detected advancing Tinel's sign in all nerve stripper-assisted sural nerve harvested group members in both the closed and limited open groups. Sural nerve harvesting by the nerve stripper is a reliable and simple technique, and it is applicable as a routine technique. Applying controlled rotatory movements of the nerve stripper instead of pushing can result in satisfactory harvesting of the sural nerve without early laceration.

Prevalence of Upper and Lower Extremity Tinel Signs in Diabetics: Crosssectional Study from a United States, Urban Hospital-based Population

Objective: To evaluate the prevalence of the Tinel Sign in the upper and lower extremities of patients with diabetes in an urban community. Methods: An IRB-approved, prospective, cross-sectional, descriptive study was performed on patients with diabetes during their visit to the endocrinologist. Eighty-one consecutive patients (162 sides) were examined by a fellowship-trained Hand Surgeon, experienced in performing the “Tinel Sign”. Mean duration of diabetes was 18.5 years. In the upper extremity known sites of anatomic entrapment were percussed; median nerve at the wrist (carpal tunnel), ulnar nerve at the elbow (cubital tunnel), radial sensory nerve in the forearm, and a negative control site. In the lower extremity, sites were tibial nerve at ankle (tarsal tunnel), proximal tibial nerve (soleal sling), common peroneal nerve at fibular neck (fibular tunnel), superficial peroneal nerve, deep peroneal nerve over dorsum of the foot, and a negative control site. Neuropathy was defined as a score greater than 4 on the Michigan Neuropathy Screening Instrument (MNSI). Statistical evaluation included linear regression, analysis of variance, and Tukey’s post hoc test. Results: 100% of the control sites had absent Tinel Sign. MNSI score and number of positive Tinel Signs were highly correlated ( r=0.94, p=0.001). Upper extremity, prevalence of Tinel Sign in patients with neuropathy (i.e. MNSI >4) ranged from 46.2% to 65% compared to 2.4% to 19.5% without neuropathy (MNSI < 4). Lower extremity prevalence ranges were 23% to 59% with neuropathy and 0% to 17.1% without neuropathy. The chances of having a positive Tinel Sign in the contralateral limb were 38.2%, 42.2%, 44.7% and 48.4% for carpal tunnel, cubital tunnel, fibular tunnel and tarsal tunnel, respectively. Conclusion: Presence of a Tinel sign was highly correlated with presence of neuropathy in diabetics.

Kinesio tape management for superficial radial nerve entrapment: A case report

This case report describes a 41-year-old female who presented with complaints of pain in the lower lateral one-third of the right radius extending into the first web space. Tinel's sign reproducing the patient's symptoms was elicited 8.2 cm above the radial styloid process. Physical diagnosis for superficial radial nerve entrapment was made based on a positive upper limb neural tension test 2a along with symptom reproduction during resisted isometrics to brachioradialis and wrist extensors. A potential first time successful conservative Kinesio tape (KT) management for entrapment of the superficial radial nerve is described in this report. An immediate improvement in grip strength and functional activities along with a reduction in pain and swelling was noted in this patient after the first treatment session, which was maintained at a 6 month follow-up. A model is proposed describing the mechanism by which KT application could be used to intervene for nerve entrapment interfaces.

Mayo Clinic Internist Offers Pearls for Eldercare

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Carpal Tunnel Syndrome with Paracoccidioidomycosis

Carpal Tunnel Syndrome with Paracoccidioidomycosis

Bilateral ulnar nerve entrapment by the M. anconeus epitrochlearis. A case report and literature review

Ulnar neuropathy at the elbow is the second most common entrapment neuropathy. Ulnar nerve entrapment has several causes. A case report is presented with the presence of the M. anconeus epitrochlearis at both sides. The patient contacted our department with chronic, diffuse bilateral elbow pain irradiating into both forearms. She experienced typical nocturnal paresthesias involving digit IV and V of both hands. Tinel's sign was present just proximal to the medial epicondyle. A bilateral ulnar nerve entrapment was clinically suspected. An electromyographic (EMG) investigation revealed slowing of the motor conduction velocity in the ulnar nerve across the elbow. An ultrasound and MRI investigation demonstrated the presence of an anomalous muscle, called the M. anconeus epitrochlearis, at both sides. Treatment consisted of bilateral surgical excision of the muscle and retinacular release, followed by physical therapy. The outcome was favourable.

Benign schwannoma of the radial nerve mimicking cervical radicular pain

Radicular pain on the arm often referred to cervical disc problems. If cervical MRI is normal, then it is necessary to rule out peripheral nerve tumor. A 54-year old man presented with radicular pain in his left arm, investigated for cervical disc problems, with normal cervical MRI. Examination shows a positive Tinel's sign on the proximal part of his left arm. Focal MRI revealed a lobulated tumor in the radial nerve 1.5 cm in diameter. The patient was operated and the tumor was completely removed. Histopathology confirmed the diagnosis of schwannoma. (Med J Indones. 2012;21:118-20)

A Positive Tinel Sign as Predictor of Pain Relief or Sensory Recovery after Decompression of Chronic Tibial Nerve Compression in Patients with Diabetic Neuropathy

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Surgical and Nonsurgical Treatment of Cubital Tunnel Syndrome in Pediatric and Adolescent Patients

Few studies have investigated the presence or treatment of cubital tunnel syndrome in pediatric or adolescent patients. We conducted this retrospective investigation to quantify success rates of nonsurgical care and to assess patient outcomes after surgical intervention. We identified 39 extremities treated for cubital tunnel syndrome between 2000 and 2009 at one institution. We documented patient demographic data, precipitating events, symptomatology, physical examination findings, and treatment for all patients. We assessed patient-rated outcomes with validated measures including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the visual analog scale (VAS). Subjective complaints at the time of presentation included 16 extremities with ulnar nerve instability at the elbow, 21 extremities with pain at the elbow, and 15 extremities with numbness and tingling in the ring and small fingers. Physical examination revealed 33 extremities with a positive Tinel sign and 20 extremities with a positive elbow flexion-compression test. In the nonsurgical group (9), pretreatment DASH scores averaged 32 and posttreatment DASH scores averaged 11. Pretreatment recall VAS pain scores had a median of 7, and were similar to posttreatment scores, which had a median of 3. In the surgical group (30), DASH scores averaged 46 before surgery and improved to 7 at final follow-up. The VAS pain scores improved from a median of 8 before surgery to 2 after surgery. A total of 30 patients (from both groups) were treated with a trial of nonsurgical care without symptom resolution. Cubital tunnel syndrome in pediatric or adolescent patients is rare. It can be treated successfully with surgical intervention. Although nonsurgical treatment is unlikely to relieve symptoms in this patient population, a trial of nighttime splinting, activity modification, and anti-inflammatory medications remains appropriate for most patients. Surgical intervention is effective for symptom relief if nonsurgical care fails. Therapeutic III.

Evaluation for Ulnar Neuropathy at the Elbow in Ironman Triathletes

Evaluation of the elbow in Ironman triathletes for ulnar compression neuropathy caused by aerobar use. Descriptive laboratory study. Ironman California 70.3, Ironman Arizona, Ironman New Orleans 70.3, San Antonio, Texas. Study 1: (n = 712) Ironman California 70.3/Ironman Arizona participants. Study 2: (n = 54) Ironman New Orleans 70.3 finishers. Study 3: (n = 11) participants training for an Ironman triathlon. Pilot questionnaire (study 1). Pilot questionnaire and prerace and postrace physical examination (study 2). Pilot questionnaire and preride and postride (and postseason) physical examination, and electrodiagnostic testing (study 3). Participants with symptoms, physical examination findings, and electrodiagnostic findings (amplitude or conduction velocity decrease) (P < 0.05). In study 1, 20.8% reported a history of ulnar symptoms. In study 2, 35.2% reported a history of ulnar symptoms. Preevent physical examination testing of the elbow showed 39.5% with positive Tinel sign and 41.5% with positive flexion/compression test. Postevent testing showed 70.4% with positive Tinel sign and 75.9% with positive flexion/compression test. In study 3, 46% reported ulnar symptoms. Preride physical examination testing showed 4.5% with positive Tinel sign and 9% with positive flexion/compression test. Postride testing showed 95.5% with positive Tinel sign and 91% with positive flexion/compression test. Postseason testing showed 64% with positive Tinel sign and 82% with positive flexion/compression test. Electrodiagnostic testing comparing preride and postride showed that ulnar nerve latency increased in 82%, amplitude decreased in 50%, and conduction velocity slowed in 64%. Electrodiagnostic testing comparing preseason and postseason showed that ulnar nerve latency increased in 73%, amplitude decreased in 64%, and conduction velocity slowed in 82%. The findings support the hypothesis of an ulnar compression neuropathy at the elbow occurring at high rates in aerobar using Ironman triathletes.

Physical therapy management of entrapment of the superficial peroneal nerve in the lower leg: A case report

This case report describes a 40-year-old male who presented with complaints of pain in the left lower lateral one-third of the leg. Tenderness was elicited 9.7 cm above the lateral malleoli with a positive Tinel's sign at the same site causing radiating pain into the foot (visual analog scale (VAS) score of 6.3 cm). Physical diagnosis for entrapment of the superficial peroneal nerve at the site of the peroneal tunnel was entertained based on clinical examination and three positive provocation tests. Conventionally, treatment for this type of entrapment has been surgical decompression by splitting the crural fascia, with successful outcomes. This is potentially a first-time report describing physical therapy management of entrapment mechanical interface with pain modalities, soft tissue mobilization, and neural mobilization. Reduction of pain was noted in this patient (VAS score of 0 cm by the sixth session) with complete pain resolution maintained at a six-month follow-up.

Proximal Stimulus Confirms Carpal Tunnel Syndrome—A New Test? —A Clinical and Electrophysiologic, Multiple-Blind, Controlled Study

In patients with carpal tunnel syndrome (CTS), a proximal stimulus can sometimes evoke typical symptoms. Explanations for this phenomenon include local disturbance of arterial circulation, stimulation of trigger points, and the double crush syndrome (DCS). The aim of this study was to investigate the value of these hypotheses with a new provocation test performed on the infraspinatus muscle (infraspinatus test [IsT]) in a multiple-blind, controlled study. Thirty-four subjects were recruited, tested with IsT, and measured with nerve conduction velocity (NCV). Additionally, the Tinel sign (TS) was examined. The McNemar test was used to compare the IsT and NCV with the subjects' symptoms. The Fisher exact test was used to correlate IsT and symptoms. In the McNemar test, IsT showed no significant difference to the NCV (P = 0.18, sensitivity: 69.7%, specificity: 87.1%) regarding the subjects' symptoms (P = 0.2888, sensitivity 80.6%, specificity 93.9%). The Fisher exact test proved the significance of the IsT with regard to symptoms (P < 0.0001). Pressure exerted on a certain point of the infraspinatus muscle has significant diagnostic power and may be a valuable clinical test in everyday practice. We discuss the arguments for and against a new, latent trigger point and whether other mechanisms may play a role.

An unusual cause of thenar hypertrophy and carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is characterized by classic symptoms of paresthesias in the median distribution and weakness that is sometimes accompanied by thenar atrophy. We describe an unusual case presenting with thenar hypertrophy. A 52 year-old, right-handed man presented with 10 years of intermittent paresthesias in the left median nerve distribution and difficulty snapping the fingers. Driving and typing worsened his symptoms. His examination revealed increased thenar bulk without focal masses (Fig. 1A). A Tinel sign was present. Sensory exam did not elicit significant abnormalities. Mild thenar weakness was noted. Electrodiagnostic studies revealed prolonged distal motor latency (7.9 ms), decreased compound motor action potential amplitude compared to the right (left 5.1 mV, right 9.2 mV) and absent left median sensory nerve action potential. Ulnar studies and F-wave latencies were normal. Needle EMG of abductor pollicis brevis showed increased insertional activity, 1+ fibrillation potentials, 2+ positive sharp waves, 3+ fasciculation potentials, increased motor unit potential (MUP) amplitude, reduced MUP recruitment and increased firing rate. Studies were consistent with left focal median neuropathy at the wrist. Figure 1 A) Thenar eminence in the symptomatic left hand is appreciably larger compared to the right. B) MR axial T1 weighted non-fat saturated image reveals linear strands of hyperintense fat (arrow) infiltrating the thenar muscles. C) MR axial fat saturated ... To further elucidate the etiology of thenar hypertrophy, MRI of the hand and wrist was performed to assess structural detail. MRI revealed linear strands of fat infiltrating thenar muscles (Fig. 1B), which was different from diffuse fibrofatty change associated with advanced muscle atrophy. There was globular enlargement of the median nerve with linear cable-like appearance of the nerve fascicles with surrounding fat. The enlargement measured 1.2 × 1.6 centimeters and was consistent with lipofibromatous hamartoma (LFH) (Fig. 1C). He underwent decompression of the nerve. Nerve enlargement and swelling was noted at the time surgery but fibrofatty change was not appreciated because of intact epineurium. Three months post-operatively, paresthesias improved. However, imaging revealed no change in the size of the median nerve mass (Fig. 1D). This case is instructive because thenar hypertrophy led to imaging, which revealed LFH. Thenar hypertrophy could result from either pseudohypertrophy or true hypertrophy related to spontaneous activity, increased work of remaining fibers, and fiber stretching 2, 3. Chronic denervation and spontaneous activity on needle EMG raises the possibility of true thenar hypertrophy. The focal, band-like pattern of fatty infiltration in thenar muscles suggests extension of LFH. If the fatty replacement were due to severe muscle atrophy, then significant clinical weakness and diffuse fibrofatty change should be present. To our knowledge, we describe the first case of thenar pseudohypertrophy likely due to extension of median nerve LFH. Besides LFH, localized hypertrophic neuropathy has been reported in hereditary sensory motor neuropathy type 1, Refsum syndrome and diabetic neuropathy 4. However, a “cable-like” appearance of the median nerve is pathognomonic for LFH and arguably nullifies the need for biopsy 5. Additionally, LFH have a predilection for the median nerve 6. The etiology of LFH is unknown. There are many proposed mechanisms including a post-traumatic reactive process, congenital and association with neurofibromatosis 7. Surgical treatment of the tumor is debated. Mass excision can lead to sensory deficits 6. In our case, an initial conservative decompression procedure resulted in improvement in sensory symptoms. LFH of the median nerve should be considered for patients who present with CTS and clinical thenar pseudohypertrophy.

HYPERVENTILATION PROVOKES SYMPTOMS OF CARPAL TUNNEL SYNDROME

Hyperventilation causes respiratory alkalosis. The nervous system is more excitable in alkalosis. This phenomenon can be observed as paraesthesia in fingers and toes as well as around the lips in anxious patients breathing rapidly. We wanted to test this phenomenon on already irritable nerves like the median nerve in carpal tunnel syndrome (CTS). We deployed 50 patients who came in to the day case unit for carpal tunnel decompression with electro-physiologically proven diagnosis. We devised a test whereby patients were made to hyperventilate under prescribed conditions and repeated Phalen's test and Tinel's sign for comparison. These were compared with a control group chosen randomly among hospital staff. 86% patients had a positive result which was just behind Phalen's test in sensitivity. It was also 100% specific as there were no false positives. Hyperventilation is a phenomenon which provokes carpal tunnel syndrome. Its clinical value remains to be seen due to cumbersome method and probable patient non-compliance but it is a new discovery. It may be useful in other irritable-nerve-syndromes as a test to add to our available armament. It may be an additional factor or a primary reason for nocturnal paraesthesias in CTS patients.