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Brief Note
Tinel’s Sign
ITS CHARACTERISTICS AND SIGNIFICANCE

BY JOSEPH MOLDAVER, M.D.*, NEW YORK, N.Y.

The clinical value of the Tinel sign remains contro- repair, when sensory fibers have reached the thumb, gently
versial, and there is a great deal of confusion as to its con- tapping the thumb may result in a tingling sensation re-
rect definition. A clean description of this sign and a better ferred to the long finger; on, gentle tapping on the index
delineation of its relative importance and of its practical finger may cause tingling in the distribution of the palmar
value are needed. cutaneous branch of the median nerve just below the wrist.
In 1915, Tinel 6 after studying a large number of pe- Aberrant regeneration of the ulnar nerve also is quite fre-
ripheral nerve injuries, described a tingling sensation or quent and is indicated by a tingling sensation in the little
so-called formication sign produced by slight percussion finger produced by percussion of the hypothenar region
of a nerve trunk some time after an injury . This creeping where ulnar sensory fibers normally are present. Similarly,
sensation, which is referred to the cutaneous distribution tapping over the first dorsal interosseus muscle may pro-
of the nerve, usually is described by the patient as being duce Tinel’s sign in the little finger, indicating that some
similar to a mild electric current. Tine! believed that this sensory skin fibers have regenerated along axons that nor-
sensation is mediated by young axis cylinders in the pro- mally supply the first dorsal interosseus muscle.
cess of regeneration. He also stated that the tingling was Tine! indicated that pressure applied to a regenerating
quite different from the pain that may result from pressure nerve trunk will cause tingling. This type of tingling is not
applied to an injured nerve. He insisted that the tingling of elicited at the point where percussion produces this sen-
regeneration is barely perceived in the area where percus- sation, but more distally where there are nascent sensory
sion is applied and radiates only into the cutaneous dis- fibers. When regenerating fibers have reached the surface
tribution of the specific nerve. According to him, this sign of the skin, Tine!’s sign can be produced by gentle tap-
appears about four to six weeks after injury and when ping, but stroking of the skin in the same area may elicit
present, permits one not only to determine the presence of the tingling sensation much better. Also, when pinprick is
regenerating nerve fibers, but also to follow the progres- used to test pain sensation the pain may be perceived as
sion of regeneration. He stressed that if the sign remains dull, but be accompanied by a spreading tingling around
fixed in one spot for several consecutive weeks or even the area stimulated because the nerve endings responsible
months, the nerve fibers, in the process of regeneration, for the tingling are stimulated by the pin.
are in an area where there is an obstacle to their growth, Percussion should be applied so as to avoid a wide-
and they are grouped together forming a neuroma. As re- spread mechanical stimulus of the nerve above the area
generation progresses the sign becomes more easily ob- being percussed. Gentle tapping with the eraser on the end
tamable on percussion of the nerve trunk or its branches, of a pencil permits stimulation of a very well localized
because more nerve fibers are present within the trunk. area and produces percussion that can be applied uniform-
However, the sign is obtainable wherever nerve fibers are ly. In eliciting the sign, it should be remembered that a
regenerating, even if they are growing aimlessly. The genuine Tinel’s sign indicating that some sensory fibers
nerve fibers that do enter endoneurial tubes are not neces- are growing is never painful .

sarily in the tubes that they were in originally or in tubes The common pins-and-needles sensation, or tingling,
that lead to the former areas of distribution of the fibers. that is experienced in many different pathological condi-
Obviously , if the location of the sign moves progressively tions, is the most frequent type of paresthesia. It is similar
in a distal direction, this is a favorable sign, but this Se- to Tinel’s sign except that it is spontaneous and can be
quence does not indicate whether the regenerating nerve constant. Such ting!ing sensations may be associated with
fibers will reach areas of the skin that correspond to the such diseases as multiple sclerosis, multiple neuropathy,
locations of the original nerve endings. The sign also does meralgia paresthetica, and latent tetany, and can also be
not give a true appreciation of the number of nerve fibers produced by mechanical pressure on a normal nerve trunk.
growing . In addition, they may occur during the early stages of local
Aberrant regeneration can often be demonstrated after anesthesia and when a tourniquet is inflated or released.
injury of any sensory or mixed nerve by the presence of An identical tingling phenomenon can be produced by
Tinel’s sign. For instance, after a median-nerve injury and stimulation of a sensory or mixed nerve through the skin
using a square-wave current, a negative pole (cathode)
* 30 East 60th Street, Suite 301, New York, N.Y. 10022. stimulating electrode which is one centimeter in diameter

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 TINEL’S SIGN 413

and applied over the nerve, and a larger position (anode) or but normal pain , touch, and temperature sensation due to
diffuse electrode applied elsewhere. The current used is multiple sclerosis, and in two patients with subacute com-
the lowest perceptible current that produces tingling, usu- bined degeneration, stimulation of a peripheral nerve
ally one to two milliamperes. Although the current is con- (median, ulnar, or common peroneal nerve) with a con-
tinuous, the sensation perceived is an soft stant current resulted in a tingling sensation comparable to
vibration felt distally in part of the cutaneous area supplied that in a normal individual.
by the nerve stimulated. By slightly moving the electrode In patients with pressure paralysis due to either tour-
oven the nerve, different fibers of the nerve trunk can be niquet or so-called Saturday-night palsy, characterized
stimulated, and the tingling is felt in different parts of the by loss of motor function and touch, sequential electrical
cutaneous area supplied by the nerve. If the strength of the studies , repeated until motor function and touch returned
current is great enough, the sensation resu!ting from stimu- to normal , showed that the last function to return to normal
lation is felt over the entire sensory distribution of the was touch, and that the tingling elicited by a constant cur-
nerve. With this type of stimulation one can easily map out rent was not obtained as long as touch remained impaired.
the sensory distribution in the hand of the median or ulnar In numerous patients with a typical Tinel sign in the
nerve. upper extremity elicited by gentle tapping over the in-
This tingling sensation is not painful but there may be volved nerve trunk or branches of the nerve distal to the
a prickling on burning sensation under the electrode. This site of injury , or tapping over the be!!y of a muscle inner-
sensation can be avoided to some extent by increasing the vated by the nerve, an attempt was made to obliterate the
stimulating current gradually until the level desired is Tinel sign by various maneuvers. When a pneumatic cuff
reached. The nerve accommodates to the stimulation and was applied above the elbow and inflated above the sys-
in the absence of the local prickling sensation at the tolic pressure, touch sensation was usually the first sensa-
cathode the patient can concentrate better on the tingling tion to be impaired. As soon as touch in the hand was
sensation. altered, the Tine! sign and the tingling sensation produced
Using this technique, patients with a variety of con- by electrical stimulation diminished and finally disap-
ditions were studied. In one with an amputation above the peared when touch was markedly depressed or absent.
elbow, the median and ulnar nerves were stimulated below These findings indicate that nerve fibers and tracts con-
the axilla roughly three months after amputation. This ducting the sensation of tingling and of pins and needles
produced a tingling sensation referred to the fingers of the are the ones that convey touch.
missing hand. In other patients with injuries of the median, A true Tine! sign, therefore, is a tingling sensation
ulnan, radial, and sciatic nerves verified at operation, elicited by stimulation of nerve branches in which touch
stimulation of the central end several years after injury re- fibers are growing. Since in a mixed nerve touch fibers ac-
sulted in a tingling sensation in the cutaneous distribution count for only about 10 per cent of all of the fibers, only a
ofeach nerve. The time between injury and stimulation did few touch fibers are needed to produce Tinel’s sign, and
appear to affect the tingling appreciably. the sign provides information about the regeneration of the
In a patient with syringomyelia, complete analgesia touch fibers but not of the other fibers.
and complete thermanesthesia on one side between the A true Tine! sign is never painful. If there is any pain
third cervical and third thoracic segments, touch, position, associated with gentle tapping of a sensory or mixed
and vibratory sense were not affected. Stimulation of the nerve, this finding should not be called Tinel’s sign, but
ulnar and median nerves at both wrists and elbows using a should be regarded as evidence of a neuroma or as a
constant current resulted in a tingling sensation that was neuroma-like sign. One must bear in mind that gentle tap-
the same on the affected and the non-affected sides. In ping oven a normal peripheral mixed nerve may produce
another patient, who had had a cordotomy in the mid- both tingling and pain, meaning that touch fibers as well as
thonacic region for intractable pain in the right thigh, there pain fibers are being stimulated. The term Tinel’s sign
was complete loss of pain and temperature sensation in the should be applied only to the paresthesias associated with
right lower extremity but other modes of sensation were nerve branches which are growing and are very sensitive to
intact. Stimulation of the common penoneal and tibia! the slightest percussion distal to the area of the nerve in-
nerves in both lower limbs caused tingling that was the jury or repair. Regenerating touch fibers are oversensitive
same in both limbs. It therefore is evident that pain, heat, to mechanical stimulation, and after they reach the skin
and cold fibers do not convey the tingling. In still another they remain hypersensitive to gentle tapping or gentle
patient who had had a preganglionic upper thoracic sym- stroking for some time.
pathectomy for causa!gia in the ulnar and median distnibu- Tinel’s sign cannot be elicited in patients with tin-
tion, the tingling sensation produced by electrical stimula- gling due to a nerve-root lesion proximal to the dorsal root
tion of the nerves with a constant current was normal. In ganglion, because the healing sensitive touch fibers are
twelve patients with absent vibratory and position sense proximal to the ganglion under these circumstances.

References
I. BRAIN, W. R.: Diseases of the Nervous System. Ed. 3. London, Oxford University Press, 1947.

VOL. 60-A, NO. 3. APRIL 1978

414 JOSEPH MOLDAVER

2. MEDICAL RESEARCH COUNCIL: Peripheral Nerve Injuries, edited by H. J. Seddon. Medical Research Council Special Report Series, no. 282.
London, H. M. S. Stationery Office, 1954.
3. MOLDAVER, J.: Fibers and Tracts Conducting Tingling of “Pins and Needles” Sensation. Trans. Am. Neurol. Assn. , pp. 189-192, 1952.
4. MOLDAVER, JOSEPH: Tourniquet Paralysis Syndrome. Arch. Surg., 68: 136-144, 1954.
5. SUNDERLAND, SYDNEY: Nerves and Nerve Injuries. London, E. and S. Livingstone, 1968.
6. Tmiai, J.: Le signe du “fourmillement” dans les lesions des nerfs p#{233}riph#{233}riques.Presse med., 23: 388-389, 1915.
7. TINEL, J.: Nerve Wounds. London, Bailli#{232}re, Tindall, and Cox, 1917.
8. TINEL, J.: Les paresth#{233}sies pr#{233}coces apr#{232}ssuture ou greffe nerveuse. Rev. neurol. , 26: 521-526, 1919.

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