Physical examination maneuver
Physical Exam
Vibratory Sensation
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With the patient’s eyes closed, strike a 128-Hz tuning fork and place its base firmly on the area being tested, preferably over a bony prominence. Ask whether they feel the vibration and have them report when it stops. At unpredictable intervals, damp the fork while it remains in place to confirm that the patient can distinguish vibration from pressure alone. Compare the same area on the opposite side.
How to Interpret
Showing all 3 findings
Carpal Tunnel Syndrome
Abnormal vibration sensation in the hand
Rule in
InconclusiveWide CI
Rule out
Not helpfulWide CI
Evidence:Moderate
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
HelpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Moderate
Reduced vibratory perception at the great toe
Rule in
Very helpfulNo CI
Rule out
Minimally helpfulDerived CI
Evidence:ModerateResearch in progress
Related Bedside Tests
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Monofilament Testing
aka Semmes-Weinstein monofilament test
Rule in:SHPeripheral Neuropathy, MHCarpal Tunnel Syndrome, NHDiabetic Foot Ulcer +1 more
Rule out:SHDiabetic Foot Ulcer, MHCarpal Tunnel Syndrome, MHPeripheral Neuropathy +1 more
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Proprioception Toe Test
Rule in:HPeripheral Neuropathy
Rule out:VHPeripheral Neuropathy
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Sharp Sensation
Rule in:HPeripheral Neuropathy, SHCarpal Tunnel Syndrome, NHLumbosacral Radiculopathy +5 more
Rule out:SHPeripheral Neuropathy, NHCarpal Tunnel Syndrome, NHLumbosacral Radiculopathy +5 more
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Achilles Deep Tendon Reflex
aka Ankle jerk
Rule in:VHPeripheral Neuropathy, SHHypothyroidism, NHLumbosacral Radiculopathy +5 more
Rule out:VHPeripheral Neuropathy, MHHypothyroidism, NHLumbosacral Radiculopathy +5 more
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Biceps Deep Tendon Reflex
aka Biceps jerk
Rule in:VHPeripheral Neuropathy, SHCervical Radiculopathy, IECervical Myelopathy +2 more
Rule out:MHPeripheral Neuropathy, NHCervical Radiculopathy, IECervical Myelopathy +2 more
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Patellar Deep Tendon Reflex
aka Knee jerk
Rule in:VHLumbosacral Radiculopathy, VHPeripheral Neuropathy, IECerebellar Disease +5 more
Rule out:SHPeripheral Neuropathy, ICLumbosacral Radiculopathy, IECerebellar Disease +5 more