Physical Examination Tests for Carpal Tunnel Syndrome and Wrist Tenosynovitis
Carpal Tunnel Syndrome Physical Tests
For carpal tunnel syndrome diagnosis, the combined wrist flexion with median nerve compression test (Durkan test) is the most clinically useful physical examination maneuver, with 82% sensitivity and 99% specificity when symptoms are reproduced within 20 seconds. 1
Primary Provocative Tests
Durkan Test (Carpal Compression with Wrist Flexion): Apply firm digital pressure across the carpal tunnel while maintaining wrist flexion for 20 seconds to reproduce paresthesias in the median nerve distribution (thumb, index, middle, and radial half of ring finger). This test demonstrates superior positive predictive values of 99%, 95%, and 81% at population prevalences of 50%, 20%, and 5% respectively. 1
Standard Carpal Compression Test (Durkan Maneuver): Apply firm digital pressure directly over the carpal tunnel without wrist positioning to reproduce symptoms. This test is 64% sensitive and 83% specific for carpal tunnel syndrome. 2
Phalen's Test (Wrist Flexion Test): Have the patient maintain maximum wrist flexion for 60 seconds to reproduce symptoms. This test shows 61% sensitivity and 83% specificity, making it less reliable than the combined compression-flexion test. 1
Reverse Phalen's Test (Wrist Extension Test): Maintain wrist extension for 60 seconds. When combined with median nerve pressure, this achieves 94% sensitivity at 60 seconds. 3
Secondary Provocative Tests
Tinel's Sign: Percuss over the median nerve at the wrist to elicit paresthesias in the median nerve distribution. This is the most specific test but least sensitive, making it useful for ruling in disease when positive but less useful for ruling out disease when negative. 4
Vibration Test: Apply vibratory stimulus to assess median nerve function. This is the most sensitive but least specific test, and cases with positive vibration tests demonstrate slower sensory nerve conduction velocity compared to negative results. 4
Clinical Examination Positioning
Patient should be seated with the hand positioned on the thigh or examination table for optimal assessment. 5
Dynamic examination with active finger flexion and extension should be performed to assess nerve mobility and symptom reproduction. 5
Important Clinical Caveats
No single physical test possesses all qualities necessary to be the ideal clinical test for carpal tunnel syndrome detection. 3
There is no correlation between the time to symptom reproduction in Phalen's test, reverse Phalen's test, or carpal compression test and nerve conduction study measurements. 4
Electrodiagnostic studies remain the gold standard for diagnosing carpal tunnel syndrome and determining severity, with approximately >80% sensitivity and 95% specificity, despite having significant false-positive and false-negative rates. 2, 6
Patients with positive Tinel and vibration tests have slower sensory nerve conduction velocities, and those with positive vibration tests have longer symptom duration. 4
Wrist Tenosynovitis Physical Tests
For wrist tenosynovitis, physical examination should focus on identifying tendon-specific pain with resisted motion and palpable swelling along tendon sheaths, with dynamic assessment during active finger flexion and extension being essential for diagnosis. 5
Examination Technique for Tenosynovitis
Patient positioning: Seated with hand resting on thigh or examination table, allowing for both static and dynamic assessment. 5
Dynamic examination: Perform active and passive flexion/extension of fingers to assess for triggering, crepitus, or pain along tendon sheaths. 5
Palpation: Systematically palpate tendon sheaths on both volar and dorsal aspects of the wrist to identify focal tenderness, swelling, or nodularity. 5
Specific Tenosynovitis Conditions
De Quervain Tenosynovitis: Involves swelling of the extensor tendons at the wrist (first dorsal extensor compartment), more common in women with median age of onset 40-59 years. Finkelstein's test (ulnar deviation of the wrist with thumb flexed into palm) reproduces pain. 2
Trigger Finger (Stenosing Tenosynovitis): Assess for abnormal resistance to smooth flexion and extension ("triggering") of affected fingers, with palpable nodularity at the A1 pulley. This affects up to 20% of adults with diabetes and approximately 2% of the general population. 2
Intersection Syndrome: Palpate for tenderness and crepitus approximately 4-6 cm proximal to the wrist where the first dorsal compartment tendons cross the second compartment. 5
Clinical Examination Findings
Tendon pathology assessment should include evaluation for tendinopathy, partial or complete tendon tears, stenosing tenosynovitis, and pulley injuries through resisted motion testing. 5
Superficial location of hand and wrist tendons makes them particularly amenable to physical examination with palpation and dynamic testing. 5
Imaging Considerations When Physical Examination is Equivocal
Ultrasound is the preferred initial imaging modality for suspected tenosynovitis due to superficial tendon location and ability to perform dynamic assessment, capable of diagnosing tendinopathy, tendon tears, intersection syndrome, stenosing tenosynovitis, and pulley injuries. 5
MRI without IV contrast can diagnose the same tendon abnormalities with superior soft tissue contrast resolution, though postcontrast images improve detection of tenosynovitis. 5
High-frequency transducers (≥10 MHz) are recommended for ultrasound evaluation to detect even minor synovitic and tenosynovial lesions. 5, 7
Common Pitfalls to Avoid
Do not rely solely on clinical examination when symptoms are atypical or when there is concern for proximal compression or other compressive neuropathies in carpal tunnel syndrome—electrodiagnostic testing should be performed. 2
Bilateral carpal tunnel syndrome without obvious cause (no rheumatoid arthritis or known trauma) may indicate systemic conditions including cardiac amyloidosis and warrants further evaluation. 7, 8
Steroid injection efficacy varies by condition: approximately 72% effective for de Quervain tenosynovitis (especially with immobilization), but less efficacious in insulin-dependent diabetes for trigger finger. 2