Arthritis Care & Research

Vol. 64, No. 2, February 2012, pp 287–289

DOI 10.1002/acr.20664
© 2012, American College of Rheumatology
BRIEF REPORT

Modified Phalen’s Test as an Aid in Diagnosing

Carpal Tunnel Syndrome
SAYEEDA BILKIS,1 DONALD M. LOVEMAN,2 JAMES A. ELDRIDGE,3 SHABNAM ASGHER ALI,4
ABDUL KADIR,5 AND WALTER MCCONATHY2

Objective. We developed a modified Phalen’s test (MPT), which uses sensory testing in Phalen’s position, as a diagnostic
screening tool for carpal tunnel syndrome (CTS). This study was designed to determine the sensitivity, specificity, and
receiver operating characteristic (ROC) curve of the MPT for diagnosis of CTS.
Methods. Electrodiagnostic nerve conduction studies (EDS) were used as the gold standard. MPT was performed by a
blinded examiner on patients prior to EDS. MPT was recorded as either positive or negative based on the presence or
absence of a median nerve sensory deficit while the hand was in Phalen’s position.
Results. Sixty-six hands were included in this study. Chi-square for the MPT compared to EDS as the gold standard was
41.449 (P < 0.001), and the validity coefficient (phi) was 0.792 (P < 0.01). The traditional Phalen’s test (TPT) compared
to the EDS demonstrated a chi-square of 15.349 (P < 0.001) and a phi coefficient of 0.482 (P < 0.01). ROC curve estimates
for the MPT revealed a sensitivity of 84.4% compared to 50% for the TPT. The standard error of the estimate for sensitivity
was 3.3% for the MPT and 5.8% for the TPT.
Conclusion. The MPT is a highly useful screening diagnostic tool for CTS. The MPT demonstrates greater accuracy than
the TPT for predicting CTS. The MPT also demonstrates greater sensitivity than the TPT in predicting a positive
electrodiagnostic test for CTS.

Introduction Consensus committees from professional societies have

Carpal tunnel syndrome (CTS) is caused by elevated pres-
sure in the carpal tunnel. Prolonged or frequent episodes
of elevated pressure in the carpal tunnel may result in
segmental demyelination associated with sensory symp-
toms and occasionally with weakness. When there is pro-
longed ischemic axonal injury, nerve dysfunction may be
irreversible (1,2).
Electrodiagnostic study (EDS) for CTS is highly specific,
reasonably sensitive (3), and helps rule out other causes of
similar signs and symptoms. EDS (nerve conduction, nee-
dle electromyography) continues to be the mainstay of
laboratory diagnosis of CTS. Furthermore, some third-
party payers require EDS before compensating claims.
1
Sayeeda Bilkis, MD: Reeves County Hospital, Pecos, Tex-
as; 2Donald M. Loveman, MD, Walter McConathy, PhD:
Texas Tech University Health Sciences Center, Odessa;
3
James A. Eldridge, EdD: University of Texas of the Permian
Basin, Odessa; 4Shabnam Asgher Ali, MD: Wayne State
University, Detroit, Michigan; 5Abdul Kadir, MD: Neurol-
ogy, Odessa, Texas.
Address correspondence to Sayeeda Bilkis, MD, Internal
Medicine, Reeves County Hospital, 2323 Texas Street,
Pecos, TX 79772. E-mail: sbilkis@hotmail.com.
Submitted for publication April 27, 2011; accepted in
revised form September 29, 2011.
endorsed EDS as the diagnostic test of choice. However,
since EDS costs $800 to $1,600, clinical history and phys-
ical examination including provocative tests are the most
appropriate initial diagnostic tools in the ambulatory set-
ting. The predictive value of these tests, however, is dis-
puted. The sensitivity of Phalen’s test and Tinel’s test is
reported to be between 25% and 75%, with specificities
between 70% and 90% (4 –7). The sensitivity of sensory
testing using Semmes-Weinstein monofilament testing
may be as high as 91%, and combining this test with
Phalen’s test may have a specificity of 86% (8,9).
Koris et al (10) studied combining Semmes-Weinstein
monofilament sensory testing during the wrist flexion
provocational test (Phalen’s maneuver) in a group of 21
patients (33 hands) with electrodiagnostically verified CTS
and 30 asymptomatic hands (controls). The combined test
demonstrated a sensitivity of 82% and a specificity of
86%. It was more sensitive and specific than the wrist
flexion test (Phalen’s test) alone and more specific than
sensory testing alone. Unfortunately, this combined test
has not been widely applied clinically, likely due to the
complexity of the approach taken by Koris et al requiring
several sensory threshold monofilament measurements.
The purpose of our study was to evaluate the validity,
sensitivity, and specificity of a simplified version of the
modified Phalen’s test (MPT) that we have developed. The

287
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Figure 1. Modified Phalen’s test consists of the traditional
Phalen’s test maneuver of holding the wrists in a position of fixed
flexion and the use of a Semmes-Weinstein 2.83-unit monofila-
ment. The filament (arrow) is applied perpendicular to the skin
surface until it bends.
goal was the development of a highly accurate and easy to
perform screening diagnostic tool for CTS.
Materials and methods
The MPT combines the traditional Phalen’s test with si-
multaneous objective sensory examination of the hand
with a standard monofilament. The traditional Phalen’s
test is considered positive if paresthesiae are reproduced
during the maneuver of holding the wrists in a position of
fixed flexion for 1 minute. The MPT places the hands as
in Phalen’s test while performing sensory testing with a
Semmes-Weinstein 2.83-unit monofilament applied per-
pendicular to the skin surface until it bends (Figure 1). The
monofilament was applied to the palmar surface and lat-
eral side of each finger’s distal phalanx 3 times. MPT was
considered positive if the subject did not register the touch
in any 1 or more fingers in a median nerve distribution
(radial 3.5 fingers on the palmar side). The MPT was con-
sidered negative if the subject correctly registered a touch.
The palmar surface of the fifth finger’s distal phalanx was
used as a control. The patient’s hands were maintained in
the flexed position throughout the testing interval.
Testing was performed in a standardized fashion by 1 of
2 trained examiners (SB, SAA). The examiner was blinded
to the diagnosis. The testing was performed prior to EDS of
the upper extremity in a neurology clinic. The inclusion
criterion was adults ages 18 years or older. Exclusion
criteria consisted of 1) cervical radiculopathy, 2) previous
Table 1. Validity of Phalen’s test compared to EDS*
Negative EDS Positive EDS
Negative Phalen’s test 20 23
Positive Phalen’s test 0 23
* Values are the number of hands. Traditional Phalen’s test: ␹2 ⫽
15.35, ␾ ⫽ 0.48, P ⬍ 0.01. EDS ⫽ electrodiagnostic study.
Bilkis et al
Table 2. Validity of the MPT compared to EDS*
Negative EDS Positive EDS
Negative MPT 20 7
Positive MPT 0 39
* Values are the number of hands. Modified Phalen’s test (MPT):
␹2 ⫽ 41.45, ␾ ⫽ 0.79, P ⬍ 0.01. EDS ⫽ electrodiagnostic study.
history of stroke, 3) diabetes mellitus, and 4) concomitant
neck injury.
Sixty-six hands of 37 patients were studied prospec-
tively from June 2007 to July 2008. Eleven men and 26
women who were between the ages of 27 and 88 years
were included in this study. Hands were tested by both
the traditional Phalen’s test and the MPT. Our gold stan-
dard determination of normal hands or hands with CTS
was based on EDS results. EDS was considered positive
for CTS if the median versus ulnar orthodromic sensory
(mixed) peak latency measurement with midpalmar stim-
ulation at 8 cm recording from the wrist showed a differ-
ence of 0.4 msec or more. Among 37 patients, 8 patients
had EDS on only 1 hand. The remainder of the patients
underwent EDS in both hands. Data were analyzed using
chi-square analysis and the resultant phi coefficient to
determine the validity of MPT compared to EDS. Receiver
operating characteristic (ROC) curves were calculated to
determine the associated specificity and sensitivity of the
MPT.
Results
To determine the concurrent validity of the MPT com-
pared to EDS, 66 hands were studied. Of those 66 hands,
46 were found to have CTS and 20 were normal by EDS.
Of these 46 hands with documented CTS, the traditional
Phalen’s test was positive for 23 hands (Table 1), whereas
the MPT was positive in 39 hands (Table 2). Also, the MPT
produced significantly fewer false-negative tests (7 hands)
when compared to the traditional Phalen’s test (23 hands).
There were no false-positive results using either the tradi-
tional Phalen’s test or the MPT. The validity of the tradi-
tional Phalen’s test and the MPT was calculated using
standard 2 ⫻ 2 chi-square analyses (Table 3). Both the
traditional Phalen’s test (␹2 ⫽ 15.35) and the MPT (␹2 ⫽
41.45) were found to be valid; however, the MPT was more
accurate (␾ ⫽ 0.79) at predicting CTS compared to the
traditional Phalen’s test (␾ ⫽ 0.48). Sensitivity and speci-
ficity of the 2 tests were analyzed using ROC curve analy-
sis techniques to further examine the accuracy of the 2
measures compared to EDS (Table 4). Both the traditional
Phalen’s test and the MPT were found to be 100% specific
Table 3. Validity of the traditional Phalen’s test and
modified Phalen’s test compared to electrodiagnostic study
Variable ␹2 ␾
Traditional Phalen’s test 15.35 0.48*
Modified Phalen’s test 41.45 0.79*
* Significant at P ⬍ 0.01.
Using Modified Phalen’s Test to Diagnose CTS
Table 4. Receiver operating characteristic curve analyses of the traditional Phalen’s test
and modified Phalen’s test
Specificity, %
95% confidence
Variable Score
Traditional Phalen’s test 100
Modified Phalen’s test 100
for the diagnosis of EDS. The MPT, however, had a greater
degree of sensitivity (85%) compared to the traditional
Phalen’s test (50%), as shown in Figure 2. Furthermore,
the standard error of the estimate for sensitivity was lower
for the MPT (3.3%) compared to the traditional Phalen’s
test (5.8%). Therefore, the MPT was more sensitive.
Discussion
Recent advances in understanding the pathophysiology of
CTS favor the concept that reduced microvascular perfu-
sion plays a major role in the early stages of median nerve
entrapment neuropathy. In patients with CTS, wrist flex-
ion results in increased pressure in the carpal tunnel,
which in turn exacerbates existing intraneural ischemia
and results in a profound conduction block (1,2,11). It has
been shown that abnormalities detected by threshold sen-
sory testing provide a sensitive indicator of clinically sig-
nificant nerve compression (4). Koris et al (10) used mul-
tiple sensory threshold monofilament sensory testing of
the hand both in neutral and Phalen’s positions. The com-
plexity of this approach is not suitable to a busy outpatient
setting. In contrast, MPT is very simple and easy to per-
form. The result of our study is comparable with the study
performed by Koris et al (10). Our study demonstrates that
the MPT is a highly useful screening diagnostic tool for
CTS. The MPT is much more sensitive than the traditional
Phalen’s test. It improved the sensitivity of the traditional
Phalen’s test by 35%, and the MPT is, therefore, less likely
to result in a false-negative diagnosis. The MPT is a very
Figure 2. Receiver operating characteristic curves showing sensi-
tivity and specificity of the traditional Phalen’s test and modified
Phalen’s test.
289
Sensitivity, %
95% confidence
interval Score interval
80–100 50 35–65
80–100 85 71–93
simple test that can be easily performed by primary care
physicians with no significant patient discomfort.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be published. Dr. Bilkis had full access
to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Study conception and design. Bilkis, Loveman, Ali, Kadir,
McConathy.
Acquisition of data. Bilkis, Loveman, Eldridge, Ali, Kadir.
Analysis and interpretation of data. Bilkis, Loveman, Eldridge,
McConathy.
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