Special Topic
The Tinel Sign: A Historical Perspective
Erika N. Davis, B.S., and Kevin C. Chung, M.D., M.S.
Ann Arbor, Mich.
The Tinel sign is one of the most well-known and widely
used clinical diagnostic tools in medicine. Aside from Jules
Tinel, after whom the sign is named, several authors have
described the famous “tingling” sign seen in regenerating
injured nerves. In fact, Tinel was not the first to present
the sign to the scientific community. The clinical value
and utility of the Tinel sign have remained in question
since its introduction; many may misinterpret the sign as
a prelude to complete functional recovery of injured
nerves, when in fact it only signals the progress of nerve
regeneration. Today the Tinel sign is widely associated
with the diagnosis of carpal tunnel syndrome and in the
evaluation of regenerating peripherally injured nerves.
Knowledge of the history and misconceptions surround-
ing the sign provides clinicians today with a greater ap-
preciation of current debates on the use of the Tinel
sign. (Plast. Reconstr. Surg. 114: 494, 2004.)
The Tinel sign is one of the best known and
widely used clinical diagnostic tools in plastic
surgery, neurology, and orthopedics. First de-
scribed in the early 1900s, the Tinel sign is the
“tingling” feeling elicited when an injured
nerve trunk is percussed at or distal to the site
of a nerve lesion. The sign indicates the level of
regeneration or localizes the level of damage to
a nerve. Over time, the sign has become asso-
ciated with the diagnosis of carpal tunnel syn-
drome and other compression neuropathies.
The Tinel sign has quite a rich history, during
which the clinical value and utilization of the
sign has been debated and misunderstood
since its introduction.
THE ORIGIN OF THE “TINGLING SIGN”
The Tinel sign is named after Dr. Jules Tinel
(1879 to 1952), a well-known French neurolo-
gist. In addition to being credited with the
discovery of the sign of regenerating axons,
Tinel was recognized for many other contribu-
tions in the field of medicine and beyond.
From the University of Michigan Medical School and the Section of Plastic Surgery, Department of Surgery, The University of Michigan Health
System. Received for publication August 11, 2003; revised October 6, 2003.
DOI: 10.1097/01.PRS.0000132675.12289.78
494
Tinel was born in Rouen, France, in 1879.
Although Tinel excelled in many disciplines,
he decided to pursue a medical career, as did
the five generations of physicians in his family
that he followed. He undertook his studies in
medicine first at Rouen. He quickly left to
continue his studies in Paris. It was in Paris that
Tinel studied under Joseph Jules Dejerine, a
well-known French neurologist, to whom he
vowed an attachment and loyalty. Dejerine had
a huge influence on Tinel’s career and di-
rected him toward the field of neurology and
neuropathology.1–3
A great deal of the advancement that was
made in the twentieth century in the diagnosis
and treatment of nerve injuries was obtained at
the expense of wounded soldiers.4 –7 For much
of Tinel’s contribution to neurology, this was
no exception. Beginning in 1914, Tinel served
as an auxiliary doctor for an infantry regiment
in the First World War. In 1915, he moved to
Mans, France, to create a neurology center. For
3 years, he extensively studied peripheral nerve
injuries resulting from gun shot wounds in
combat.1–3,8,9 As a result of this work, Tinel
drew conclusions on the nature and severity of
nerve lesions, giving him a better understand-
ing of the treatments required. This experi-
ence led him to observe the Tinel sign, which
he referred to as the “sign of formication”
(pins and needles), in patients with nerve in-
juries.9 In October of 1915, Tinel published his
observation of the tingling sign observed when
the trunk of an injured nerve is lightly per-
cussed some time after injury.5,10 –12 He wrote
that “pressure applied to an injured nerve
trunk frequently produces a sensation of tin-
gling which the patient feels in a precise loca-
tion at the periphery of the nerve . . . tingling is
Vol. 114, No. 2 / HISTORICAL PERSPECTIVE ON TINEL
a sign of regeneration, or more precisely, tin-
gling reveals the presence of regenerating ax-
ons.”13 Tinel went on to publish an extensive
and renowned volume on the symptomatology
and treatment of nerve wounds in 1916 (trans-
lated into English in 1917),9 based on his study
of 693 patients with nerve lesions. In this work,
entitled Les Blessures des Nerfs (Nerve Wounds),
Tinel restated the importance of the sign of
formication in the clinical evaluation of pe-
ripheral nerve injuries and in observing the
progress of nerve regeneration.
Aside from making strides in the treatment
of nerve injuries, Tinel was responsible for
publishing numerous works in the domain of
neurology, endocrinology, and psychiatry. Spe-
cifically, Tinel made important contributions
in the study of the autonomic nervous system.
He also produced a thick volume on the sub-
ject in 1936 entitled Le Système Nerveux Végétatif
(The Vegetative Nervous System). This work was
one of the first summations of the physiology
of the autonomic nervous system.1–3,14
Later in his career, Tinel divided his efforts
among patients, research, and the French Re-
sistance. Beginning in 1942, he participated in
the resistance network Comete, where he hid
Allied pilots who crashed on French soil in his
home until his son Jaques could drive them
across France to Spain. After his son did not
return from one of these dangerous missions,
Tinel learned of Jaques’s arrest and incarcera-
tion in Bordeaux, France, at Fort Ha. Several
days later, Tinel and the rest of his family were
imprisoned in Fresnes, France. Soon, the
Comete network was completely annihilated.
After several months, everyone except for
Jaques was freed. In 1945 Tinel learned that his
son had died as a result of the conditions at
Dora, the German concentration camp to
which he was deported.1–3
Despite Tinel’s important contributions to
medical research and the French Resistance,
according to his colleagues, he maintained
such humility that he never endeavored to
profit or seek fame from his role in either
affair. Tinel was remembered for the kindness
and devotion that was particularly known by his
patients. Extensively devoted to research and
his patients, Tinel continued to work until his
death from heart failure in 1952.1–3,15
In the first half of the twentieth century,
Tinel’s name became associated with the re-
generation sign, but he was not the first to
present the sign that is commonly seen in re-
SIGN 495
generating nerves. A great deal of literature
written in the latter half of the twentieth cen-
tury regarding the Tinel sign acknowledges
that Paul Hoffmann, a German physiologist,
presented the “tingling” sign before Ti-
nel.4,5,12,16 –19 For this reason, in some recent
literature, the Tinel sign is also referred as the
Hoffmann-Tinel sign, giving credit to both
men.
Paul Hoffmann (1884 to 1962) was born in
Dorpat, Germany, in 1884.12 He attended med-
ical school at the Universities of Fezpig, Mar-
burg, and Berlin from 1905 to 1909 and was
later known as the originator of modern neu-
rophysiology in Germany.4,16 Paul Hoffmann
also treated casualties in the First World War
but on the opposite front as Tinel. The two
scientists were unaware of each other’s work
because they were unable to freely communi-
cate between the fighting countries.12 Hoff-
mann published two papers on the percussion
test, the first in March of 1915,20,21 which intro-
duced the sign, and the second a few months
later, which presented the percussion test in
greater detail.22 Hoffmann wrote that “it would
be a great comfort to the patient if one could
evaluate the success of the [nerve] suture early
in the course . . . there are sensory fibers in the
proximal nerve stump, and stimulation of
these fibers should create a sensation referred
to the insensitive cutaneous area. These fibers
grow after the nerve has been sutured.”20 He
described this as the “percussion test,” which
today is most commonly referred to as the
Tinel sign.16
Both men hypothesized that a positive sign
indicated the presence of young axons in the
process of regeneration.9,11,13,20 –22 There are
fundamental differences, however, between
their observations. Whereas Hoffmann ob-
served that the percussion test signified the
regeneration of sensory fibers and not motor
fibers, Tinel did not address this limitation.
Although a positive sign could indicate that the
return of motor function is possible, it is not a
guarantee of motor regeneration.22 Another
theory that Hoffmann presented was that re-
generating nerve fibers have an extremely low
stimulation threshold compared with normal
nerves. Thus, Hoffmann recommended using
light pressure when conducting the test be-
cause a normal intact nerve can be stimulated
with a much higher intensity of pressure.21 Ti-
nel, however, provided virtually no instruction
on the method used to elicit the tingling sign.
496
Likewise, Tinel presented original ideas of
his own. Whereas Hoffmann presented the use
of the sign in a more cursory fashion, Tinel’s
book Nerve Wound9 allowed him to address the
application of the sign in greater detail. Tinel
extensively discussed syndromes of complete
nerve interruption, compression, irritation,
and regeneration. In all of these cases, he out-
lined when to expect the formication sign; he
used the sign to assess the condition of the
patient and to determine whether there was a
need for surgical intervention. For example,
the tingling sign can be seen in a limited zone
at the level of a nerve injury, corresponding to
the presence of a neuroma. Tinel hypothesized
that if the tingling remained fixed at the site of
injury for months, it is a sign of complete or
partial interruption of the nerve and the need
for surgical exploration; nerve fibers have be-
gun to regenerate but are unable to pass the
site of the lesion.9 In addition, Tinel addressed
the difference between pain and tingling, both
of which may be seen on stimulation of the
injured nerve trunk. Tinel explained that pain
signifies the presence of an irritated nerve,
whereas tingling signifies the presence of a
regenerating nerve. From his observations, he
stated that the sign is usually seen 4 to 6 weeks
after trauma; when the nerve is in the process
of regenerating, the formication sign can take
8 to 10 months, or longer, to disappear.9,11
Although the scientific community has be-
gun to recognize Hoffmann for describing the
percussion test before Tinel, it has not been
widely noted that neither scientist was the first
to describe this sign. In 1909, Trotter and Da-
vies first described in great detail the occur-
rence of peripheral reference in nerve inju-
ries.23,24 Trotter and Davies wrote, “during a
certain period following the nerve section,
from about the second to the sixth week, hy-
peralgesia may appear. A large number of sen-
sations elicited from a recovering area are re-
ferred to distant parts of the area or to the
point of the nerve section.”23 Trotter and Da-
vies suggested, however, that during regenera-
tion, nerve fibers responsible for perceiving
sensations of cold, pain, or touch would refer
their sensations along their distribution pe-
ripherally if stimulated appropriately.23 In real-
ity, only nerve fibers that perceive touch are
responsible for generating a true Tinel sign.10
It is probable that as Hoffmann and Tinel
treated their respective patients in the World
War, they were aware that stimulation of an
PLASTIC AND RECONSTRUCTIVE SURGERY, August 2004
injured nerve would produce a peripherally
referred sensation, as reported by Trotter and
Davies. Before Hoffmann and Tinel’s work was
published, however, the sign was merely a phe-
nomenon with no known value. Although
Hoffmann and Tinel were not the first to de-
scribe the sign, they were the first to fully de-
scribe clinical application of the phenomenon.
There have been many theories as to why the
percussion test is most often referred to as the
Tinel sign rather than crediting Hoffmann or
Trotter and Davies. One theory is that Tinel
had greater experience in the field of neurol-
ogy and the treatment of nerve injuries than
the other scientists that described the percus-
sion test.16 It has also been suggested that the
outcome of the World War, with Hoffmann on
the losing side, made his work less valued in
the scientific community than Tinel’s. 5,12
Widely used texts that were published soon
after the introduction of the tingling sign, such
as Babcock’s Textbook of Surgery,25,26 gave recogni-
tion only to Tinel. It is most probable that
because widely distributed materials only cred-
ited Tinel, his name became solely associated
with the sign. Also, physicians treating nerve
injuries after both World Wars eagerly sought
Tinel’s comprehensive publication, Nerve
Wounds. This made Tinel better recognized
than the others who described the sign before
him.12,16,27,28
CHANGES IN PUBLIC ACCEPTANCE
Since its inception, the use and public accep-
tance of the Tinel sign has gradually changed.
Response soon after the publication of Hoff-
mann’s and Tinel’s papers was rather nega-
tive.24,29 This was largely because Tinel heavily
emphasized that a positive sign indicated re-
covery. Once clinicians realized that a positive
Tinel sign did not assuredly result in a positive
functional outcome, the immediate result was
strong opposition to the clinical use of the
sign.24 It is very doubtful that those who were
against the use of the Tinel sign for this reason
were aware that this limitation was first cau-
tioned by Hoffmann in 1915.22
More dissent resulted when cases were dis-
covered in which the tingling sign was present
in nerves that were anatomically separated.24 In
reality, cases with grossly separated nerve end-
ings had no chance of recovering without sur-
gical intervention, yet the clinician might be-
lieve that spontaneous recovery is likely if
percussion of the nerve lesion elicits tingling.
Vol. 114, No. 2 / HISTORICAL PERSPECTIVE ON TINEL
As a result, the scientific community refuted
Tinel’s assertion that a positive sign was an
accurate prediction of spontaneous recovery.
Clinicians found the sign to lack significance
not only because there where cases in which
the Tinel sign was present in patients who had
complete interruptions but also because there
were instances where the Tinel sign was absent
in patients who went on to fully recover from
nerve injury.24,29 By the Second World War, the
Tinel sign was described in many general text-
books but the majority of neurologists and neu-
rosurgeons did not use the sign clinically.24 –26
Early on it was misunderstood that the value
of the sign was not to predict with certainty a
functional recovery but to indicate whether
nerve regeneration was able to progress to
some degree past the site of injury. A positive
tingling sign meant that some regeneration
was occurring whether the regenerating nerves
were in a neuroma or not. The most important
clinical information was progression of the sign
seen with frequent evaluation of the patient.9
Not until 1946 was the scientific community
reminded by Nathan and Rennie of the essen-
tial informative element of the Tinel sign:
whether the sign was progressive.29 In the same
year, Napier also provided support to the value
of the sign. Napier studied the cases of nerve
lesions with large anatomical gaps that had a
positive tingling sign. He observed that a Tinel
sign could not be elicited distal to the site of
injury. This was an indication of a neuroma, as
Tinel originally hypothesized.9,24 In addition,
because of cases in which a Tinel sign was
absent in patients who went on to fully recover,
Nathan and Rennie29 disagreed with Tinel’s
original claim that a negative tingling sign in
most cases indicated a bad prognosis and need
for surgical intervention.9 Thus, a negative Ti-
nel sign alone does not provide the clinician
with enough information to determine the ne-
cessity of surgical exploration. A positive sign
that is progressing, however, signifies that re-
generating nerves are able to pass the lesion; a
sign that is static at the site of injury indicates
the presence of a neuroma and the need for
exploration.
THE TINEL SIGN AND CARPAL TUNNEL SYNDROME
With the passage of time, the Tinel sign spe-
cifically became associated with the diagnosis
of carpal tunnel syndrome. As with the use of
the Tinel sign in assessing nerve injuries, its
value in aiding in the diagnosis of entrapment
SIGN 497
neuropathies has also been heavily debat-
ed.30 –36 Although early work on carpal tunnel
syndrome failed to mention the use of the
Tinel sign,37 as early as 1950, Phalen popular-
ized percussion of the median nerve beneath
the transverse carpal ligament, giving credit
only to Tinel for this sign.36,38 – 40 Phalen con-
cluded that a positive Tinel sign was among the
most reliable of diagnostic findings. After gain-
ing extensive experience in treating patients
with carpal tunnel syndrome, Phalen contin-
ued to give his support that the Tinel sign is
one of the most important clinical findings in
diagnosing carpal tunnel syndrome.41– 44 His
studies reported sensitivity of Tinel sign rang-
ing from 60 to 73 percent in patients with
carpal tunnel syndrome.41,43,44 Because Phalen
did not use electrodiagnostic tests in determin-
ing whether his patients had carpal tunnel syn-
drome, however, his findings continue to be
debated.
More recent studies using electrodiagnostic
criteria as the standard in diagnosing carpal
tunnel syndrome report sensitivities of the Ti-
nel’s sign ranging from 25 to 79 percent and
specificities ranging from 59 to 94 per-
cent.31,33–35 Although there is disagreement as
to the true value of the Tinel sign in diagnos-
ing carpal tunnel syndrome, several studies31,32
show the sign as having one of the highest
specificities among many physical examination
tests used. Ghavanini and Haghighat reported
that among five clinical tests (Tinel’s, Phalen’s
(wrist flexion), reverse Phalen’s (wrist exten-
sion), carpal compression, and vibration test-
ing) the Tinel sign was the most specific (84
percent), but the least sensitive (32 percent).32
One might conclude that a patient with a pos-
itive Tinel sign and positive history likely has
carpal tunnel syndrome, but a negative sign
does not exclude carpal tunnel syndrome.32,35,36
Thus, the Tinel test is a useful adjunct in the
physical exam of patients suspected of having
carpal tunnel syndrome, but it must be consid-
ered along with many other clinical factors.
CONCLUSIONS
Since its first mention, the application and
value of the Tinel sign has continued to change
within the scientific community. Initially, there
was an overemphasis on the ability of the Tinel
sign to positively predict a successful recovery.
Though Hoffmann addressed the inherent
weakness of the sign in not predicting regen-
eration of motor nerves, his ideas about the
498
tingling sign received little recognition until
recently. Likewise, Tinel suggested that the
sign was useful to evaluate the progress of re-
generation only if monitored over a period of
several months in frequent evaluations of the
patient. This piece of information was virtually
forgotten for nearly 30 years. Nevertheless,
these ideas that were originally presented by
Hoffmann and Tinel still have value today. Al-
though the Tinel sign has continued to reserve
its place in many clinical diagnostic and sur-
gery texts in the evaluation of nerve injury and
carpal tunnel syndrome,45– 47 there continues to
be much debate over the use of the sign.
Kevin C. Chung, M.D., M.S.
Section of Plastic Surgery
The University of Michigan Health System
1500 E. Medical Center Drive
2130 Taubman Center
Ann Arbor, Mich. 48109-0340
kecchung@med.umich.edu
ACKNOWLEDGMENTS
The authors are very grateful to Frank Lau and Dr. Richard
Klein for their help with French translations.
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