Physical Exam

Vibratory Sensation

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Video coming September 2026

How to Perform

Strike a 128 Hz tuning fork and place its base on a distal bony prominence (for example, the dorsum of the interphalangeal joint of the great toe), with the patient's eyes closed. Ask the patient to report when they feel the vibration and the moment it stops. If vibration is not felt distally, move to a more proximal bony point (medial malleolus, then tibial tuberosity).

How to Interpret

Peripheral Neuropathy

Lower-extremity bedside cluster positive (≥2 of 3: Achilles reflex absent despite facilitation, vibration <10 seconds at toe with 128-Hz tuning fork, or position sense <8 of 10 1-cm trials at toe)

Rule in

Helpful

Rule out

Very helpful

Evidence:Limited

References

Kanji JN, Anglin RES, Hunt DL, Panju A. Does this patient with diabetes have large-fiber peripheral neuropathy? JAMA. 2010 Apr 21;303(15):1526-1532. doi:10.1001/jama.2010.428. PMID: 20407062. JAMA Rational Clinical Examination series (original article). Systematic review of 6 primary diagnostic accuracy studies; reference standard nerve conduction studies; MEDLINE 1966-November 2009 + EMBASE 1980-2009. Note: LR data reported as ranges across the 6 included studies; no pooled meta-analytic estimates with confidence intervals.
Richardson JK. The clinical identification of peripheral neuropathy among older persons. Arch Phys Med Rehabil 2002;83(11):1553-1558. doi:10.1053/apmr.2002.35656. PMID 12422324.
McGee S. Evidence-Based Physical Diagnosis. 6th ed. Philadelphia, PA: Elsevier; 2025.