Phalens Test: What It Shows and How to Apply It
December 1, 2025
6 min. read
Carpal tunnel syndrome (CTS) continues to be one of the most common upper-extremity conditions seen in rehabilitation settings. The Phalen's test remains one of the most recognized physical examination tools for identifying symptoms associated with median nerve compression. While the test is simple to administer, understanding when and how to use it, how to interpret findings, and how it fits within a broader evaluation strategy is key for consistent clinical decision-making.
This article provides a clear overview of the Phalen's test, including what it assesses, how to administer it, supporting evidence, and an example of how it may be applied during an upper-extremity evaluation.
1. What the Phalen's Test Assesses
The Phalen's test, sometimes called the “wrist-flexion test,” is used to provoke symptoms associated with carpal tunnel syndrome by placing the wrist in sustained flexion. Flexing the wrist increases pressure within the carpal tunnel, which can irritate or compress the median nerve. Symptom provocation during the test may help clinicians determine whether a patient’s complaints relate to median nerve compression.
Purpose of the Test
Screen for symptoms related to carpal tunnel syndrome
Reproduce median nerve–related numbness, tingling, burning, or pain
Compare symptom response with other provocative tests, special tests, or functional movements
Support assessment findings when combined with history, symptom patterns, strength, and sensory data
Physiological Basis
Wrist flexion decreases carpal tunnel space and may increase pressure on the median nerve. Individuals with median nerve irritation may report symptom reproduction when the canal is placed under additional stress1. Reproduction of symptoms in the thumb, index finger, middle finger, and radial half of the ring finger is consistent with a positive response.
2. How to Perform the Phalen's Test
The Phalen's test is performed with passive or active wrist flexion, typically for up to 60 seconds. The test should be performed in a comfortable and controlled manner to minimize unnecessary pain or guarding.
Step-by-Step Instructions
Ask the individual to relax both arms.
Flex both wrists and press the dorsal surfaces of the hands together.
Maintain the wrist-flexed position for up to 60 seconds.
Observe for symptom reproduction, including numbness, tingling, or discomfort in the median nerve distribution.
Document symptom onset time, distribution, and intensity.
Positive Test
A positive Phalen's test occurs when the individual reports numbness or tingling within the median nerve distribution during sustained wrist flexion1.
Common Modifications
Reverse Phalen's (Prayer Test): Palms together with wrist extension, helpful for those who cannot tolerate flexion.
Unilateral Testing: Useful when one hand is more symptomatic.
Shorter Hold Time: Symptoms may appear in seconds, which is still clinically relevant.
3. Evidence and Diagnostic Utility
While the Phalen's test is widely used, it is important to interpret it within the context of a full evaluation.
Diagnostic Accuracy
Studies report variability in sensitivity and specificity depending on posture, duration, and diagnostic criteria. Systematic reviews and meta-analyses suggest general values of:
Sensitivity: ~68%2
Specificity: ~73%2
These findings demonstrate that the Phalen's test is a helpful tool, but should be paired with:
Symptom history
Sensory assessment
Strength testing (particularly thenar musculature)
Other special tests, such as Tinel’s sign
Functional reports related to fine motor tasks or repetitive wrist activities
Interpretation Considerations
A positive test does not confirm CTS in isolation. Symptoms can overlap with pronator syndrome, cervical radiculopathy, or generalized neuropathy. This reinforces the importance of incorporating multiple data points rather than relying on a single test.
4. Example: Applying Phalen's Test During an Evaluation
Below is a realistic example illustrating how the Phalen's test can support clinical decision-making during an upper extremity assessment.
Case Scenario
A 46-year-old person presents with:
Gradual onset of numbness and tingling in the thumb, index, and middle fingers
Nighttime symptoms disrupting sleep
Difficulty gripping objects at work
Intermittent wrist discomfort
Evaluation Steps and Use of Phalen's Test
History and Subjective Findings
The individual reports worsening paresthesia during prolonged typing, with relief upon rest or shaking out the hand.
Observation and Screening
Mild thenar weakness is noted. Sensory changes are present in the median nerve distribution.
Special Testing: Phalen's Test
The individual is instructed to press the dorsal surfaces of both hands together with wrists fully flexed.
Symptoms appear after 18 seconds.
Tingling localizes to the thumb, index finger, and middle finger.
Symptoms resolve once the wrists return to neutral.
Interpretation
The findings support a clinical impression of carpal tunnel syndrome when combined with symptom behavior, sensory findings, and functional complaints.
Follow-Up
An initial plan may include:
Adjusting repetitive wrist activity
Neutral wrist positioning or splinting
Tendon-gliding practice
Strength and neuromuscular re-education
Workstation strategies
Referral for electrodiagnostic studies if symptoms progress
This example demonstrates how the Phalen's test complements a broader exam.
5. Practical Tips for Incorporating the Phalen's Test
Document Specific Symptoms
Note which digits are involved. Symptoms outside the median nerve distribution may suggest alternative diagnoses.
Record Onset Time
Tracking onset time across visits provides insight into symptom progression or improvement.
Use Bilateral Comparison
Comparisons can clarify chronicity or reveal compensatory patterns.
Integrate Functional Questions
Relate findings to specific tasks such as typing, gripping, or lifting.
Putting it All Together
The Phalen's test is a straightforward and widely used tool for provoking symptoms associated with carpal tunnel syndrome. Its value lies in its simplicity, reproducibility, and relevance when paired with history, sensory findings, strength testing, and functional assessment.
The Phalen’s test is just one of many tools available to help clinicians diagnose and manage musculoskeletal conditions with greater precision. At Medbridge, we equip providers with the knowledge and resources they need to elevate care—from exam technique to evidence-informed decision-making.
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References
American Academy of Orthopaedic Surgeons. Carpal Tunnel Syndrome – OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome
MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004;17(2):309-319. https://www.jhandtherapy.org
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