Lichtman Test: A Trusted Clinical Guide to Midcarpal Instability Diagnosis
What Is the Lichtman Test?
The Lichtman Test—also known as the Midcarpal Shift Test or Catch-Up Clunk Test—is a provocative clinical examination designed to assess midcarpal instability (MCI) of the wrist. First described by Dr. David M. Lichtman, this test remains one of the most important bedside tools for identifying a condition that is often misdiagnosed as more common carpal dissociations.
Midcarpal instability is a complex wrist disorder in which the proximal and distal carpal rows fail to move smoothly together. Instead, the proximal row remains abnormally flexed while the distal row translates volarly during ulnar deviation. When the wrist reaches a critical point, the carpal rows suddenly “catch up,” producing a characteristic—and often painful—clunk.
The Lichtman Test is specifically indicated when a patient presents with ulnar-sided wrist pain, a painful click during movement, or a sensation of the wrist “giving way.” Routine X-rays are frequently normal in these patients, making clinical provocation tests essential for diagnosis.
How to Perform the Lichtman Test
Proper technique is critical for obtaining a valid result. The procedure, as described by Lichtman and colleagues, is performed as follows:
- Patient Positioning: The patient is seated with the elbow flexed to approximately 90° and resting on a firm surface. The forearm is pronated and stabilized by the examiner’s non-dominant hand in about 15° of ulnar deviation.
- Hand Placement: With the dominant hand, the examiner takes the patient’s hand into full radial deviation, keeping the wrist in a neutral position. The examiner’s thumb is placed over the dorsum of the distal capitate.
- Application of Load: An anteriorly (volar) directed load is applied through the capitate, and the examiner notes the amount and ease of translation.
- Provocation: While maintaining the volar load and axial compression, the examiner passively moves the patient’s wrist from radial deviation into full ulnar deviation.
The test may be repeated with slight variations in forearm rotation to maximize sensitivity, as some patients reproduce symptoms only in specific positions.
What Does a Positive Lichtman Test Mean?
A positive Lichtman Test is defined by the reproduction of a painful, palpable, or audible “catch-up clunk” as the wrist approaches terminal ulnar deviation. This clunk represents the abrupt reduction of the proximal carpal row from its abnormal flexed position into extension, as the capitate engages the lunate and the hamate engages the triquetrum under compressive load.
Crucially, pain reproduction is essential for a clinically meaningful positive result. A clunk alone, without the patient’s symptoms, is not considered diagnostic, as asymptomatic clunking can occur in normal wrists.
A positive test indicates injury or laxity of the palmar arcuate ligament and the dorsal triquetrohamate ligament, which normally stabilize the midcarpal joint. The finding is strongly associated with palmar midcarpal instability (PMCI), a condition that can cause significant disability if left untreated.
Evidence and Clinical Utility
The Lichtman Test is supported by peer-reviewed research. The original description by Lichtman et al. (1981) established the clinical pattern of ulnar midcarpal instability, noting that symptoms are “reproduced by ulnar deviation, axial compression, and pronation of the wrist”. A subsequent quantitative study by Feinstein, Lichtman, and colleagues (1999) validated the clinical midcarpal shift test against a mechanical testing system, confirming its usefulness as a diagnostic indicator of midcarpal nondissociative carpal instability.
Lichtman and Wroten (2006) further emphasized that the test is the premier clinical diagnostic tool for identifying patients with midcarpal instability, with reproduction of the painful clunk considered positive for the disorder. While the test is highly subjective, its correlation with objective carpal translation has been demonstrated, supporting its role in clinical practice.
Frequently Asked Questions (FAQ)
Q1: Is the Lichtman Test the same as the Midcarpal Shift Test?
Yes. The Lichtman Test, Midcarpal Shift Test, and Catch-Up Clunk Test are different names for the same clinical examination used to assess midcarpal instability.
Q2: What is the difference between a positive Lichtman Test and a normal wrist?
In a normal wrist, the carpal rows move smoothly from radial to ulnar deviation without a sudden catch. A positive test produces a painful, palpable clunk as the proximal row suddenly extends to catch up with the distal row.
Q3: Can the Lichtman Test be positive in asymptomatic people?
A clunk alone can occur in normal, asymptomatic individuals. Therefore, the test is only considered positive when the clunk reproduces the patient’s typical pain or symptoms.
Q4: What should I do if my Lichtman Test is positive?
A positive Lichtman Test should be interpreted in the context of your clinical history and imaging. It suggests midcarpal instability, and you should discuss further evaluation and management options with a qualified hand or wrist specialist.
Q5: Is the Lichtman Test reliable?
The test is widely used and has been validated against objective measures of carpal translation. However, like many provocative wrist tests, it is somewhat subjective, and its accuracy depends on examiner technique and patient response.
References
- Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability—clinical and laboratory analysis. J Hand Surg Am. 1981;6(5):515-523. PubMed
- Feinstein WK, Lichtman DM, Noble PC, Alexander JW, Hipp JA. Quantitative assessment of the midcarpal shift test. J Hand Surg Am. 1999;24(5):977-983. PubMed
- Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg Am. 2006;31(3):491-498. PubMed
- Orthofixar. Lichtman Test for Midcarpal Instability. https://orthofixar.com/special-test/lichtman-test-wrist/
- Demystifying Palmar Midcarpal Instability. PMC, National Center for Biotechnology Information. PMC Article