ARTICLE IN PRESS

HAND ELEVATION TEST FOR ASSESSMENT OF CARPAL

TUNNEL SYNDROME
R. AMIRFEYZ, C. GOZZARD and I. J. LESLIE
From the Hand Division of Department of Trauma and Orthopaedic Surgery, Bristol Royal Infirmary, Bristol, UK

The Hand Elevation test is a new provocative test for the diagnosis of carpal tunnel syndrome. We
have investigated the sensitivity and specificity of this test in 48 patients with a clinical diagnosis of
carpal tunnel syndrome and compared it to Tinel’s and Phalen’s tests. The Hand Elevation test was
found to be 88% sensitive and 98% specific. This test is a simple, reproducible provocative test
which is easily employed in conjunction with other known tests to assist in the diagnosis of carpal
tunnel syndrome.
Journal of Hand Surgery (British and European Volume, 2005) 30B: 4: 361–364

Keywords: hand elevation test, carpal tunnel syndrome, diagnostic tests for carpal tunnel syndrome

INTRODUCTION known peripheral neuropathy (other than carpal tunnel

The diagnosis of carpal tunnel syndrome is largely
dependent on symptoms and clinical signs. The com-
monly used provocative tests are Tinel’s, or the Nerve
Percussion test, and Phalen’s test. Other provocative
tests are the Durkan’s compression test (Durkan, 1991;
Paley and Mc Murty, 1985), the clenched fist test (Yii
and Elliot, 1994), the reverse Phalen’s test and the
tourniquet test (Gilliat and Wilson, 1953). Unfortu-
nately, the results are significantly influenced by
technique of examination. Therefore, the reported
sensitivities and specificities of these tests are quite
variable (Brüske et al., 2002; Durkan, 1991; González
Del Pino et al., 1997; Kuhlman et al., 1997). The use of
these tests is not always diagnostic. This highlights the
need for other clinical tests for the evaluation of carpal
tunnel syndrome. Ideally these tests should be easy to
perform, reproducible, specific and sensitive.
This study investigated the sensitivity and specificity
of the Hand Elevation test for diagnosing carpal tunnel
syndrome. The results were compared to Tinel’s and
Phalen’s tests, pre- and postoperatively.
PATIENTS AND METHOD
Study group
We studied 48 patients with presumed carpal tunnel
syndrome in 60 hands prospectively between March and
August 2003. Their mean age was 56 (range 27–92)
years. Sixteen of the 48 (33%) were men and 32 (67%)
were women. Twelve had bilateral involvement. In the
bilateral cases, the most symptomatic hand, which was
subsequently operated upon first, was considered for the
purpose of the study.
Patients with radiculopathy, a previous history of a
stroke, diabetes mellitus, a concomitant neck injury, or a
syndrome) were excluded from the study.
A diagnosis of carpal tunnel syndrome was made by
taking a detailed history, paying particular attention to
the distribution of paraesthesiae in the sensory distribu-
tion of the median nerve in the hand, disturbance of
sleep by pain and numbness in the thumb, index and
middle fingers, often relieved by shaking the wrist, and
aggravating factors such as holding a newspaper,
holding a phone to the ear and driving. Examination
included the cervical spine, palpation of the median
nerve along its course, especially in the forearm,
alteration of sensation in the median nerve distribution,
the function of abductor pollicis brevis and at least one
positive provocative test of Tinel’s test and Phalen’s test.
Whilst some may regard the gold standard for
diagnosis of carpal tunnel syndrome as being abnormal
nerve conduction studies, it has been reported that up to
25% of patients may have normal studies yet have a
clinical diagnosis of carpal tunnel syndrome and have
their symptoms relieved by carpal tunnel release (Braun
and Jackson, 1994; Concannon et al., 1997; Grundberg,
1983; Kitsis et al., 2002; Stevens, 1987; Witt et al., 2004).
Furthermore, in the United Kingdom, it is not possible,
from a logistic or financial point of view, to obtain nerve
conduction studies on every case of carpal tunnel
syndrome with a positive history and clinical examina-
tion. In our practice, nerve conduction studies are
undertaken only when the clinical diagnosis is in doubt.
Therefore, we have taken the gold standard for the
diagnosis of the carpal tunnel syndrome as an immedi-
ate resolution of the nocturnal or provoked symptoms
and improvement in sensory change in the hand within 3
months following surgery, which we have taken as the
cut off point for the purpose of this study.
All patients were reviewed pre-operatively on the
morning of surgery and the Hand Elevation test, Tinel’s
test and Phalen’s test were performed on both hands.
The unaffected side, or the side which was not scheduled
for surgery first in bilateral cases, was tested first,

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362
followed by the affected side (the side which was due to
undergo surgery first in bilateral cases). Patients were
informed of the purpose of the examination and verbal
consent obtained.
The requirement for postoperative follow-up by
phone and the method of the Hand Elevation test were
fully explained. The patients were subsequently tele-
phoned 3 months postoperatively, asked about their
symptoms and instructed to perform the Hand Eleva-
tion test.
Control group
During the same period, an equivalent number of
patients with lower limb injuries were randomly selected
and evaluated in the same manner. Any patient in this
group with symptoms of carpal tunnel syndrome,
radiculopathy, concomitant neck injury, stroke, diabetes
mellitus or any type of peripheral neuropathy was
excluded. Forty-seven patients were recruited. One hand
was excluded because it had suffered a concomitant
injury, leaving 93 hands. The mean age of the controls
was 57 (range 23–94) years. Twenty-six (55%) were men
and 21 (45%) were women. The purpose of the study
was explained and verbal consent obtained before the
Hand Elevation, Tinel’s and Phalen’s tests were
performed on both hands. A number was allocated to
each hand in the control group and, by using the table of
random numbers, 47 hands were recruited. Each time
that a hand was selected, the contralateral hand was
excluded from the population, to ensure employment of
only one hand from each individual.
Provocative tests
Two standard provocative tests (Tinel’s and Phalen’s)
were used and compared with the Hand Elevation test.
The order of testing was the Hand Elevation test, Tinel’s
test then Phalen’s test, with 2 minutes rest for complete
recovery between the tests.
Hand elevation test
Patients were asked to elevate their hand above their
head as high as comfortably possible and to hold it in
that position for 1 minute. The test was considered
positive if the patient reported symptoms similar to
those of which they had complained of at presentation.
The test was negative if the patient was asymptomatic
after 1 minute. Tingling and numbness in the tip of
the thumb, index or middle finger was the major
symptom of which patients complained during this test.
The unaffected hand was examined followed by the
symptomatic hand. In the bilateral cases, the less
symptomatic hand was tested first followed by the more
symptomatic one.
THE JOURNAL OF HAND SURGERY VOL. 30B No. 4 AUGUST 2005
Tinel’s test
Percussion was performed over the course of the median
nerve just proximal to and over the carpal tunnel with
the wrist in a relaxed position (201 of extension). If
asymptomatic on first tapping, this was repeated up to
six occasions. If still asymptomatic the test was negative.
A positive test was associated with paraesthesiae in the
median nerve distribution, or an electric shock-like
sensation passing into the hand or forearm, as originally
described by Tinel, although this test was initially used
to follow the regeneration of an injured nerve (Tinel,
1915). As a consequence, when used in carpal tunnel
syndrome, this test is often called the Nerve Percussion
test.
Phalen’s test
Patients fully palmar flexed the wrist with the elbow in
full extension and the forearm in pronation. The test
was negative if the patient was asymptomatic after
1 minute. A positive test occurred if the symptoms with
which the patient had presented were reproduced.
Phalen originally described this test with the elbow in
flexion (Phalen, 1966). However many believe that
flexing the elbow can put extra pressure on the median
nerve at more proximal levels.
Statistical analysis
Sample size was calculated prospectively on the basis of
90% power of the test statistic with a 0.05 two-sided
significance level to detect the difference between group
1 with proportion of 0.8 positive HET (study group) and
group 2 with proportion of 0.05 (control group).
The calculated sensitivities and specificities of the
three tests were based on calculations of confidence
intervals (including the results from the control group).
McNemar’s Test Statistic (with continuity corrected
P-values) was used to study the differences in the
proportions of positive results for the three tests in
patients with affected hands and the difference in hand
elevation test pre- and postoperatively (excluding the
control group).
RESULTS
Of the 48 hands in the study group, 42 (88%) had a
positive Hand Elevation test before surgery, compared
with only one of the 47 hands (2%) in the control group.
Following surgery, two hands (4%) had a persistent
sensory deficit and positive Tinel’s, Phalen’s and Hand
Elevation tests at 3 months, although their nocturnal
symptoms had disappeared immediately after surgery.
This persistence of sensory deficit may reflect chronic
axonal damage to the median nerve in these two upper
limbs, which can take much longer to resolve, if it does
at all.
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HAND ELEVATION TEST
Table 1—Sensitivity, specificity, positive predictive value, negative predictive value and efficiency of the three provocative tests (based on preop patients
group and the control group)
Sensitivity (95% C.I.) Specificity (95% C.I.)
Hand Elevation test 88% 98%
(81–94) (95–100)
Tinel’s test 48% 94%
(38–58) (89–99)
Phalen’s test 83% 98%
(76–91) (92–100)
PPV, positive predictive value; NPV, negative predictive value; C.I., confidence interval.
Table 1 compares the sensitivities, specificities,
positive predictive values, negative predictive values
and efficiencies of these tests.
A statistically significant difference was found be-
tween pre- and postoperative Hand Elevation test
results (Po0:0005). We found the Hand Elevation test
and Phalen’s test were significantly more sensitive and
specific than Tinel’s test (P ¼ 0:0003 for Phalen’s test
and P ¼ 0:00003 for the Hand Elevation test). However,
no significant difference was seen between sensitivities
and specificities of Phalen’s test and the Hand Elevation
test (P ¼ 0:56).
DISCUSSION
Carpal tunnel syndrome can usually be diagnosed
clinically and, in our unit, the commonly used provocative
tests are Tinel’s (or the Nerve Percussion) and Phalen’s
tests. Electrodiagnostic studies may be helpful in equivocal
cases, but if the symptoms and clinical signs are suggestive
of carpal tunnel syndrome they may add little but cost to
the management and outcome (Concannon et al., 1997).
Unfortunately, the sensitivity and specificity of Tinel’s
and Phalen’s tests varies in different studies (sensitivity
of 48–77% and specificity of 47–84% for Tinel’s test;
sensitivity of 28–61% and specificity of 80–94% for
Phalen’s test) (González Del Pino et al., 1997). This
variability may reflect the fact that the results of these
tests depend to a large degree on how they are
performed and the examination technique can vary
between examiners (especially for Tinel’s test). As a
result, they have low interobserver reliability and there is
a need for more valid tests. In our study, we performed
the Phalen’s test slightly differently to the original
description, with the elbow in extension instead of
flexion. Done in this way, the observer presses the
median nerve only at the level of the carpal tunnel. The
results we obtained from Phalen’s test are similar to the
previously reported results in the literature. Tinel’s test
was carried out as described by Tinel (1915).
363
PPV (95% C.I.) NPV (95% C.I.) Efficiency (95% C.I.)
98% 88% 93%
(95–100) (82–95) (87–98)
88% 64% 71%
(82–95) (54–73) (61–80)
98% 85% 91%
(94–100) (78–92) (85–96)
The pathophysiology of carpal tunnel syndrome is not
entirely clear. However, there is evidence of higher
pressure in the carpal tunnels of patients as compared to
the normal population (Gelberman et al., 1981). Increased
carpal tunnel pressure will compress the nerve and may
compromise the microcirculation of the nerve by com-
pressing vessels in the perineurium. We think that it is
probable that the Hand Elevation test further reduces the
blood supply of an already compromised nerve by
reducing local blood pressure and, thus, reproduces the
symptoms. In the Hand Elevation test, elevation of the
hand above the head and observation of the reproduction
of symptoms are all that is necessary to determine a
negative or positive test. It is easily performed, has a high
interobserver reliability, is reproducible and does not need
any additional instruments in the clinic. All of the patients
in the current study performed it without difficulty.
However, we are aware that some patients with restricted
shoulder function might find it difficult to hold the hand
above the head, in which case the test could not be used. A
similar problem also arises when carrying out Phalen’s test
in patients with limited wrist flexion. Arm elevation may
aggravate a Thoracic Outlet Syndrome. However, this
usually produces symptoms in the ulnar two fingers and
along the medial aspect of the forearm, whereas the Hand
Elevation test for carpal tunnel syndrome should produce
symptoms in the radial side of the hand to be positive.
One previous paper has described the Hand Elevation
test and reported its sensitivity as 76% and its specificity
as 99% (Ahn, 2001). However, this study of 200 patients
was confined to the female population and no post-
operative data was presented. The current study has
recorded better sensitivity and the same specificity as the
previous study and shown that it applies to both the
male and female population.
We employed the test postoperatively to compare
with pre-operative results and found that the Hand
Elevation test and Phalen’s test had superior sensitivity
and specificity to Tinel’s test. We recommend its use, as
a simple and reliable, additional provocative test in the
diagnosis of carpal tunnel syndrome.
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Acknowledgement
The authors wish to thank Mr. Stuart Harris, Senior Statistician and
RDSU Coordinator, Southmead Hospital, Bristol, UK, for his help
and support with the statistical analysis of this paper.
References
Ahn DS (2001). Hand elevation: a new test for carpal tunnel syndrome.
Annals of Plastic Surgery, 46: 120–124.
Braun RM, Jackson WJ (1994). Electrical studies as a prognostic
factor in the surgical treatment of carpal tunnel syndrome. The
Journal of Hand Surgery, 19A: 893–900.
Brüske J, Bednarski M, Grzelec H, Zyluk A (2002). The usefulness of
the Phalen test and the Hoffmann–Tinel sign in the diagnosis of
carpal tunnel syndrome. Acta Orthopædica Belgica, 68: 141–144.
Concannon MJ, Gainor B, Petroski GF, Puckett CL (1997). The
predictive value of electrodiagnostic studies in carpal tunnel
syndrome. Plastic and Reconstructive Surgery, 100: 1452–1458.
Durkan JA (1991). A new diagnostic test for carpal tunnel syndrome.
The Journal of Bone and Joint Surgery, 73A: 535–538.
Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson
WH (1981). The carpal tunnel syndrome, a study of carpal canal
pressures. The Journal of Bone and Joint Surgery, 63A: 380–383.
Gilliat RW, Wilson TG (1953). A pneumatic-tourniquet test in the
carpal tunnel syndrome. Lancet, 2: 595–597.
González Del Pino J, Delgado-Martı́nez AD, González González I, Lovic
A (1997). Value of the carpal compression test in the diagnosis of
carpal tunnel syndrome. The Journal of Hand Surgery, 22B: 38–41.
Grundberg AB (1983). Carpal tunnel syndrome in spite of normal
electromyography. The Journal of Hand Surgery, 8A: 348–349.
THE JOURNAL OF HAND SURGERY VOL. 30B No. 4 AUGUST 2005
Kitsis CK, Savvidou O, Alam A, Cherry RJ (2002). Carpal tunnel
syndrome despite negative neurophysiological studies. Acta Ortho-
paedica Belgica, 68: 135–140.
Kuhlman KA, Hennessey WJD (1997). Sensitivity and specificity of
carpal tunnel syndrome signs. American Journal of Physical
Medicine and Rehabilitation, 76: 451–457.
Paley D, McMurtry RY (1985). Median nerve compression test in
carpal tunnel syndrome diagnosis reproduces signs and symptoms
in affected wrists. Orthopaedic Review, 14: 411–415.
Phalen GS (1966). The carpal tunnel syndrome. 17 years’ experience in
diagnosis and treatment of 654 hands. The Journal of Bone and
Joint Surgery, 48A: 211–228.
Stevens JC (1987). The electrodiagnosis of carpal tunnel syndrome.
Muscle and Nerve, 10: 99–113.
Tinel J (1915). Le signe du ‘‘fourmillement’’ dans les lésions des nerfs
periphériques. La Presse Médicale, 47: 388–389.
Witt JC, Hentz JG, Stevens JC (2004). Carpal tunnel syndrome with
normal nerve conduction studies. Muscle and Nerve, 29:
515–522.
Yii NW, Elliot D (1994). A study of the dynamic relationship of the
lumbrical muscles and the carpal tunnel. The Journal of Hand
Surgery, 19B: 439–443.
Received: 16 January 2004
Accepted after revision: 11 April 2005
Dr Rouin Amirfeyz, Flat 208, 51 02 Apartments, St. James Barton, Bristol BS1 3LY, UK.
Tel.: +44 117 9048311.
E-mail: ramirfeyz@yahoo.com
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights
reserved.
doi:10.1016/j.jhsb.2005.04.007 available online at http://www.sciencedirect.com