Phalen Test

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 Phalen Test


What is Phalen Test?

Phalen Test (wrist flexion sign) is used to evaluate the median nerve compression in the case of Carpal tunnel syndrome.

It was first described by George S. Phalen, an American orthopedist.

See Also: Carpal tunnel syndrome

How do you perform Phalen test?

Phalen Test
Phalen Test

What does a positive Phalen Test mean?

What is a Reverse Phalen Test?

A reverse Phalen test (Prayer test) is also used to evaluate the median nerve compression in the case of Carpal tunnel syndrome.

Reverse Phalen Test
Reverse Phalen Test

Wrist flexion Test

Wrist flexion test is a similar maneuver to phalen test, it’s used to diagnosis the Carpal tunnel syndrome as well.

The patient is positioned in sitting with the elbow fully extended, the forearm in supination, and the wrist flexed to 60 degrees. The clinician applies an even constant pressure over the median nerve at the carpal tunnel using the thumb.

A positive test for CTS is the reproduction of symptoms along the median nerve distribution within 30 seconds.

Tetro and colleagues found this test to have a sensitivity of 86 percent and a specificity of 95 percent.

Phalen’s Test Accuracy

The original Phalen test has demonstrated a a high sensitivity and a moderate specificity making it moderately acceptable for use in clinical practice:1

While in Reverse Phalen Test, a study by de Krom and colleagues 2 found the test to have a sensitivity of 41 % and a specificity of 55 %.

In another study, Werner and colleagues 3 showed that Reverse Phalen Test results in a significantly higher intracarpal canal hydrostatic pressure as compared to a traditional Phalen or a modified Phalen maneuver and may add to the sensitivity of conventional screening methods.

In one study to assess the usefulness of the Phalen test and the Hoffmann Tinel sign in the diagnosis of Carpal tunnel syndrome, the sensitivity and specificity of the Phalen test was respectively 855 and 89%, and for the tinel test, 67 and 68%.

Notes

Some studies have varied this test to be performed by the patient with wrist in complete flexion and elbow extended, bilateral wrist flexion with the posterior aspect of the hand pressing against one another, or passive wrist flexion by the clinician.

Carpal tunnel syndrome

Carpal tunnel syndrome is a cause of chronic wrist pain and functional impairment of the hand. It results from an ischemic compression of the median nerve at the wrist as it passes through the carpal tunnel.

Compression of the nerve in the carpal tunnel is compounded by an increase in synovial fluid pressure and tendon tension, which decreases the available volume.

The compression of the median nerve may result from a wide variety of factors that compromise the tunnel space such as:

  1. fluid retention, which occurs during pregnancy, Infection and conditions such as renal dysfunction.
  2. In addition, several disease conditions, such as gout or pseudogout, acromegaly, or amyotrophy can also decrease the tunnel size.
  3. About half of the cases of Carpal tunnel syndrome are related to repetitive and cumulative trauma in the workplace.
  4. Forceful and repetitive contraction of the finger flexors can also provoke Carpal tunnel syndrome.
  5. Acute wrist trauma has also been associated with Carpal tunnel syndrome.
  6. Other causes include collagen disorders, flexor tenosynovitis, diabetes, hypothyroidism, and hemodialysis.
  7. Less common causes include instances where the lumbrical muscles encroach within the tunnel during finger movements or become hypertrophied.

Carpal tunnel syndrome more commonly occurs between the fourth and sixth decades.

Carpal tunnel syndrome is the most common compression neuropathy, with a prevalence of 9.2 % in women and 0.6 % in men.

The initial characteristic features of Carpal tunnel syndrome include intermittent pain and paresthesias in the median nerve distribution of the hand which progressively become more persistent as the condition progresses.

Carpal tunnel syndrome
Carpal tunnel syndrome

Reference

  1. Katz JN, Larson MG, Sabra A, et al: The Carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 112:321–327, 1990. PMID: 2306060
  2. de Krom MC, Knipschild PG, Kester AD, et al: Efficacy of provocative tests for diagnosis of Carpal tunnel syndrome. Lancet 335:393–395, 1990.
  3. Werner RA, Bir C, Armstrong TJ: Reverse Phalen’s maneuver as an aid in diagnosing Carpal tunnel syndrome. Arch Phys Med Rehabil 75:783–786, 1994.
  4. Tetro AM, Evanoff BA, Hollstien SB, et al: A new provocative test for Carpal tunnel syndrome. Assessment of wrist flexion and nerve compression. J Bone Joint Surg Br 80:493–498, 1998.
  5. Werner RA, Bir C, Armstrong TJ. Reverse Phalen maneuver as an aid in diagnosing Carpal tunnel syndrome. Arch Phys Med Rehabil. 1994 Jul;75(7):783-6. PMID: 8024425.
  6. Slater RR Jr, Bynum DK: Diagnosis and treatment of Carpal tunnel syndrome. Orthop Rev 22:1095–1105, 1993.
  7. Gerardi JA, Mack GR, Lutz RB: Acute Carpal tunnel syndrome secondary to septic arthritis of the wrist. J Am Osteopath Assoc 89:933–934, 1989.
  8. Sawaya RA, Sakr C. When is the Phalen’s test of diagnostic value: an electrophysiologic analysis? J Clin Neurophysiol. 2009 Apr;26(2):132-3. doi: 10.1097/WNP.0b013e31819d8046. PMID: 19279501.
  9. Phalen GS: The Carpal tunnel syndrome: Clinical evaluation of 598 hands. Clin Orthop 83:29–40, 1972.
  10. Phalen GS: Spontaneous compression of the median nerve at the wrist. JAMA 145:1128–1133, 1951.
  11. Onieal M-E: Essentials of Musculoskeletal care, 1st ed. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1997.
  12. Katz JN, Larson MG, Sabra A, et al: The Carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 112:321–327, 1990.
  13. Brüske J, Bednarski M, Grzelec H, Zyluk A. The usefulness of the Phalen test and the Hoffmann-Tinel sign in the diagnosis of Carpal tunnel syndrome. Acta Orthop Belg. 2002 Apr;68(2):141-5. PMID: 12050999.
  14. Cunha TAL, Oliveira OM, Ribeiro MB. PHALEN TEST POSITIVATION TIME AND ITS CORRELATION WITH ELECTRONEUROMYOGRAPHY. Acta Ortop Bras. 2020 May-Jun;28(3):114-116. doi: 10.1590/1413-785220202803225744. PMID: 32536790; PMCID: PMC7269134.
  15. Clinical Tests for the Musculoskeletal System 3rd Edition.
  16. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  17. Sarvdeep S. Dhatt, Sharad Prabhakar – Handbook of Clinical Examination in Orthopedics.




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