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Radial Tunnel Syndrome

Radial tunnel syndrome refers to a painful condition provoked by compressive entrapment of the radial nerve, namely the segment passing through the radial tunnel. The latter is situated distal of the elbow and extends from the radiocapitellar joint to the supinator muscle.


Presentation

RTS is a rare, potentially debilitating condition dominated by lateral elbow pain [3]. In affected individuals, repeated or forceful forearm rotation or elbow extension may exacerbate symptoms. This also applies for resisted forearm supination with an extended elbow and resisted middle finger extension [8]. Furthermore, palpation of the radial tunnel, i.e., the area located about 5 cm distal of the lateral epicondyle of the humerus, usually aggravates pain. Next to the moderate to severe pain there may be muscle weakness and decreased motion ranges. Sensory alterations, such as paresthesias and dysesthesias, are not present.

Of note, it is not uncommon that RTS patients present with what they refer to as tennis elbow. Although workup should yield a precise diagnosis, both conditions have been known to occur as comorbidities [9].

Soft Tissue Swelling
  • The following techniques may be employed: Plain radiography is often carried out to rule out acute injuries of the skeleton, to visualize possible joint effusions, soft tissue swelling and solid neoplasms.[symptoma.com]
  • Continued Conservative treatments for radial tunnel syndrome include medications such as nonsteroidal anti-inflammatory drugs to reduce soft tissue swelling, corticosteroid injections to relieve inflammation and pressure on the radial nerve, and wrist[webmd.com]
Asymptomatic
  • MR images of the asymptomatic volunteers were reviewed to establish the normal appearance of the radial tunnel.[ncbi.nlm.nih.gov]
  • The maximal difference in these recordings, the differential latency, in 25 patients with radial tunnel syndrome of greater than 6 months duration (test group) was compared with those in 25 asymptomatic volunteers (control group).[ncbi.nlm.nih.gov]
Tinel's Sign
  • Lateral epicondylitis can cause similar tenderness around the lateral epicondyle but does not cause the Tinel sign (paresthesia elicited by percussion over a nerve) or tenderness along the course of the radial nerve (which travels under the mobile wad[msdmanuals.com]
  • There is pain around the elbow on resisted extension of the middle finger Tinel’s sign is positive. Nerve conduction test may be positive. Note : PIN syndrome is distinct from RTS in that patients with PIN syndrome have a significant motor deficit.[physiowarzish.in]
  • Reproduction of symptoms during resisted extension of the middle finger suggests compression of the posterior interosseous nerve beneath the extensor carpi radialis brevis (Resisted long finger extension, aka, Middle finger sign). (3) Tinel sign or reproduction[chiroup.com]
Joint Effusion
  • The following techniques may be employed: Plain radiography is often carried out to rule out acute injuries of the skeleton, to visualize possible joint effusions, soft tissue swelling and solid neoplasms.[symptoma.com]
Suggestibility
  • Definitive evidence in the literature to support the conservative interventions suggested is lacking. Suggestions for clinical management and study are included in this therapist's clinical perspective.[ncbi.nlm.nih.gov]
  • There is no scientific evidence to suggest a direct causal relationship between work practices and radial tunnel syndrome.[ncbi.nlm.nih.gov]
  • Based on their results they suggest that great caution has to be taken before performing radial tunnel release, and strict adherence to the indications should be noted during the preoperative examination.[ncbi.nlm.nih.gov]
  • Recent studies have suggested that the PIN is "fixed" in the supinator muscle and that wrist pronation is the actual movement that places the most stress on the PIN.[ncbi.nlm.nih.gov]
Confusion
  • The syndrome is often confused with tennis elbow, although the patient may have both problems. The diagnosis remains clinical, and surgical decompression of the nerve in the region of the supinator will give relief in most cases.[ncbi.nlm.nih.gov]
  • Because it is often confused with enthesitis of the epicondyle muscle insertions (an entity often occurring simultaneously), differential diagnosis is necessary with treatment-resistant epicondylitis.[ncbi.nlm.nih.gov]
  • The condition is often confused with tennis elbow. The radial nerve travels through an open space surrounded by muscle and bone, (called the radial tunnel) along the outer side of the elbow and then to the hand.[guildfordupperlimb.co.uk]
  • This condition is often confused with tennis elbow. Causes This problem is linked to a tight space in your elbow called the “radial tunnel.” Your nerve passes through this tunnel. Inside, it can be squeezed by surrounding tissues.[theneuromedicalcenter.com]
  • Clinically, the radial tunnel syndrome can occasionally be confused with tennis elbow ( lateral epicondylitis ). tennis elbow ( lateral epicondylitis ) golfer's elbow ( medial epicondylitis ) supinator syndrome posterior interosseous nerve syndrome Promoted[radiopaedia.org]
Neglect
  • Despite numerous reports on the surgical management of this disorder, it remains largely unrecognized and often neglected. The symptoms of radial tunnel syndrome can resemble those of tennis elbow, chronic wrist pain or tenosynovitis.[ncbi.nlm.nih.gov]

Workup

If a patient presents symptoms consistent with RTS, he/she should be queried about their occupation and possibly prolonged elbow extension and forearm rotation. Alternatively, RTS patients may report prior trauma. While a considerable subset of cases is still deemed idiopathic, RTS may also indicate ongoing inflammatory processes or space-occupying lesions like cysts and neoplasms [10]. In this context, a tentative diagnosis based on anamnestic and clinical data should be supported by imaging findings. The following techniques may be employed [11]:

  • Plain radiography is often carried out to rule out acute injuries of the skeleton, to visualize possible joint effusions, soft tissue swelling and solid neoplasms.
  • Ultrasonography allows for a reliable assessment of the radial nerve's condition [5].
  • Magnetic resonance imaging may be reserved for cases of chronic elbow pain and non-responders [4].

Electromyographic studies don't usually yield specific findings. Ferdinand et al. analyzed the electromyographic examination findings of 10 patients diagnosed with RTS and could not find evidence of RN or PIN dysfunction in either one [4].

Treatment

  • Treatment should be started conservatively; if not successful, surgical treatment is indicated. The posterior interosseous nerve may be explored through dorsal or anterior approaches.[ncbi.nlm.nih.gov]
  • The most effective treatment is surgical, releasing all possible nerve compression sites.[ncbi.nlm.nih.gov]
  • A trial of nonsurgical treatment is warranted in all patients. Patients who do not respond or continue to progress despite conservative treatment are candidates for surgical decompression.[ncbi.nlm.nih.gov]
  • The effectiveness of conservative treatments for RTS is unknown because, for most treatments, no studies were available.[ncbi.nlm.nih.gov]

Prognosis

  • With appropriate treatment, the prognosis is improved Please find comprehensive information on Radial Nerve Dysfunction regarding definition, distribution, risk factors, causes, signs & symptoms, diagnosis, complications, treatment, prevention, prognosis[dovemed.com]
  • Treatment and prognosis Treatment is usually conservative. Some authors suggest surgical decompression to avoid permanent nerve damage.[radiopaedia.org]
  • S upinator (distal border) Natural History Describe the natural history,epidemiology and prognosis Patient History and Physical Findings History: Forearm pain. There is no motor deficit as in posterior interosseous syndrome.[orthopaedicsone.com]
  • Esther J Waugh, Susan B Jaglal, Aileen M Davis, George Tomlinson and Molly C Verrier, Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy, Archives of Physical Medicine and Rehabilitation, 10.1016/S0003-9993(03[doi.org]

Etiology

  • Supraglenoid cysts of the shoulder, meniscal cysts in the knee, and dorsal wrist ganglia are routinely treated with arthroscopic decompression or excision with management of the underlying etiology of the cyst.[ncbi.nlm.nih.gov]
  • […] synonyms: Radial Tunnel Syndrome ICD-10 G56.32 Lesion radial nerve, left upper limb G56.33 Lesion radial nerve, bilateral upper limbs G56.30 Lesion radial nerve, unspecified upper limb G56.31 Lesion radial nerve, right upper limb Radial Tunnel Syndrome Etiology[eorif.com]
  • Other possible etiologies for posterior interosseous nerve dysfunction include trauma (Monteggia fractures [21] ), synovitis (rheumatoid), tumors, and iatrogenic injuries.[emedicine.medscape.com]
  • Etiology The theory is that the radial nerve becomes irritated and/or inflamed from friction caused by compression by muscles in the forearm. [1] Some speculate that Radial Tunnel Syndrome is a type of repetitive strain injury (RSI), but there is no detectable[neuropaxclinic.com]
  • Radial tunnel syndrome: An etiology of chronic lateral elbow pain. J Orthop Sports Phys Ther. 1991;14(1):14-17 Novak CB. Upper extremity work-related musculoskeletal disorders: a treatment perspective. J Orthop Sports Phys Ther. 2004;34:628–37.[thesportsphysiotherapist.com]

Epidemiology

  • S upinator (distal border) Natural History Describe the natural history,epidemiology and prognosis Patient History and Physical Findings History: Forearm pain. There is no motor deficit as in posterior interosseous syndrome.[orthopaedicsone.com]
  • Radial Tunnel Syndrome ICD-10 G56.32 Lesion radial nerve, left upper limb G56.33 Lesion radial nerve, bilateral upper limbs G56.30 Lesion radial nerve, unspecified upper limb G56.31 Lesion radial nerve, right upper limb Radial Tunnel Syndrome Etiology / Epidemiology[eorif.com]
  • Epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management and prevention. Sports Med. 2006;36(2):151-170. Jalovaara P, Lindholm RV. Decompression of the posterior interosseous nerve for tennis elbow.[thesportsphysiotherapist.com]
Sex distribution
Age distribution

Pathophysiology

  • The theory is that the radial nerve becomes irritated and/or inflamed from friction caused by compression by muscles in the forearm.Some speculate that Radial Tunnel Syndrome is a type of repetitive strain injury (RSI), but there is no detectable pathophysiology[en.wikipedia.org]
  • Introduction A compressive neuropathy of the posterior interosseous nerve (PIN) with pain only no motor or sensory dysfunction, and EMG/NCS is not useful Pathophysiology involves same sites of compression as PIN syndrome, which include (from proximal[orthobullets.com]
  • Nens van Alfen, Clinical and pathophysiological concepts of neuralgic amyotrophy, Nature Reviews Neurology, 10.1038/nrneurol.2011.62, 7, 6, (315-322), (2011). Charles P. Toussaint, Edward C. Perry, Marc T. Pisansky and Douglas E.[doi.org]
  • The theory is that the radial nerve becomes irritated and/or inflamed from friction caused by compression by muscles in the forearm. [1] Some speculate that Radial Tunnel Syndrome is a type of repetitive strain injury (RSI), but there is no detectable pathophysiology[neuropaxclinic.com]

Prevention

  • My staff and I at the Nebraska Hand & Shoulder Institute, P.C. believe that prevention and elimination of painful or debilitating conditions of the upper and lower extremities can consistently be achieved.[carpaltunnelrelief.net]
  • The goal of treatment is to prevent the return of symptoms. If the job is causing the problem, the work site may need to be changed. More breaks may be needed during the workday and heavy pulling and pushing should be avoided if possible.[selectorthopedic.com]
  • As with most injuries, prevention is the best medicine. It’s important to take frequent breaks when twisting the forearm, extending the wrist or gripping to prevent an overuse injury from occurring.[reboundmd.com]
  • Prevention It may not be possible to prevent some injuries.[intermountainhealthcare.org]
  • […] cases of cubital tunnel syndrome often respond to physical therapies such as: Avoidance of undue pressure on the elbow during daily activities Wearing a protective elbow pad over the "funny bone" during daily activities Wearing a splint during sleep to prevent[webmd.com]

Summary

The radial nerve (RN) originates from the brachial plexus, descends through the radial groove of the humerus, and pierces through the lateral intermuscular septum to emerge about 10 cm proximal of the lateral epicondyle of the humerus. The nerve comes to lie between the brachialis and brachioradialis muscles. Up to this point, branches innervating the triceps brachii, anconeus, brachioradialis, and extensor carpi radialis longus muscles, and cutaneous branches have emanated from the RN. Anterior to the lateral epicondyle of the humerus, the RN divides into its two terminal branches: a superficial sensory branch and a deep motor branch. The latter then travels through an enclosed space extending from the radiocapitellar joint to the proximal aspect of the supinator muscle. This space is known as the radial tunnel, and it is delimited by the joint capsule (proximally), the brachialis muscle and biceps tendon (medially), the brachioradialis, extensor carpi radialis longus and brevis muscles (laterally), and the supinator muscle (distally) [1]. After exiting the radial tunnel, the nerve penetrates the supinator muscle and gives off several minor branches that innervate the dorsally located extensor muscles.

The compressive entrapment of the nerve within the radial tunnel causes symptoms consistent with radial tunnel syndrome (RTS). A literature review reveals a certain inconsistency regarding the use of medical termini concerning RTS [2]. On the one hand, distal segments of the deep motor branch of the RN are also referred to as posterior interosseous nerve (PIN), but the point of transition is poorly defined. Therefore, RTS may be defined as an entrapment of the deep motor branch of the RN or PIN [3] [4]. The deep motor branch of the RN penetrates the supinator muscle after it passes under the arcade of Fröhse, a fibrous arch that constitutes the most common site of entrapment of the nerve [5]. Affected individuals are diagnosed with posterior interosseous nerve syndrome, an entity to be distinguished from RTS. Finally, RTS is different from tennis elbow, although historic publications refer to the former as "resistant tennis elbow with a nerve entrapment" [6] [7].

References

Article

  1. Choi SJ, Ahn JH, Ryu DS, et al. Ultrasonography for nerve compression syndromes of the upper extremity. Ultrasonography. 2015;34(4):275-291.
  2. Schnall SB, Wongworawat MD. Apparent inconsistency regarding the nomenclature of the branches of the radial nerve near the elbow. J Hand Surg Am. 2002;27(5):916-917.
  3. Hazani R, Engineer NJ, Mowlavi A, Neumeister M, Lee WP, Wilhelmi BJ. Anatomic landmarks for the radial tunnel. Eplasty. 2008;8:e37.
  4. Ferdinand BD, Rosenberg ZS, Schweitzer ME, et al. MR imaging features of radial tunnel syndrome: initial experience. Radiology. 2006;240(1):161-168.
  5. Raeburn K, Burns D, Hage R, Tubbs RS, Loukas M. Cross-sectional sonographic assessment of the posterior interosseous nerve. Surg Radiol Anat. 2015;37(10):1155-1160.
  6. Kotnis NA, Chiavaras MM, Harish S. Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation. Skeletal Radiol. 2012;41(4):369-386.
  7. Moradi A, Ebrahimzadeh MH, Jupiter JB. Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. Arch Bone Jt Surg. 2015;3(3):156-162.
  8. Cha J, York B, Tawfik J. Posterior interosseous nerve compression. Eplasty. 2014;14:ic4.
  9. Kaswan S, Deigni O, Tadisina KK, Totten M, Kraemer BA. Radial tunnel syndrome complicated by lateral epicondylitis in a middle-aged female. Eplasty. 2014;14:ic44.
  10. Mileti J, Largacha M, O'Driscoll SW. Radial tunnel syndrome caused by ganglion cyst: treatment by arthroscopic cyst decompression. Arthroscopy. 2004;20(5):e39-44.
  11. Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014;89(8):649-657.

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Last updated: 2018-06-22 00:43