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RADIAL TUNNEL

SYNDROME
ELBOW DIFFERENTIAL DIAGNOSIS

Arises from the posterior cord of the brachial plexus,


receiving neuronal contributions from cervical roots
C5-C8 (Barnum et al, 1996)

RADIAL NERVE
ANATOMY

Passes from posterior to anterior compartment of the


arm by piercing the lateral intermuscular septum, a
site for neuronal compression associated with
fractures (Barnum et al, 1996)
Then nerve travels anteriorly between the brachialis
muscle and biceps tendon medially, and lateral to the
brachioradialis , extensor carpi radialis brevis (Barnum
et al, 1996)

SITES OF ENTRAPMENT
Four most common sites for entrapment
1) 4) Arcade of Frohse Inverted arched structure that lies within 1 cm distal of
the fibrous edge of the ECRB and approximately 2 cm distal to the elbow joint
Most common (Barnum et al, 1996)
2) Inconsistent fascial bands or adhesions connecting the brachialis to the brachioradialis that
overlie the nerve at the level of the radial head
3) Leash of Henry a fan of vessels arising from the radial recurrent artery and its venous
counterparts to superficially cross the nerve at the level of the radial neck
Barnum et al, 1996)
4) Medial proximal portion of the Extensor Carpi Radialis Brevis (ECRB)

ARCADE OF FROHSE

(Barnum et al, 1996)

WHAT ARE WE LOOKING FOR?


RTS occurs most often in the dominant arm in those performing manual work or athletic activities that
require strenuous, repetitive movements of the upper extremity (Barnum et al, 1996
Repetitive pronation/supination movement = leading cause of RTS
4th 6th decade of life, men and women equally effected
Insidious onset (not a traumatic event)
Poorly localized, dull pain over radial proximal forearm that may radiate proximally along the radial nerve
is the hallmark (Barnum et al, 1996)
Pain is proximal radial part of forearm, which is aggravated by work but also present at rest, and intense tenderness
over posterior interosseous nerve, especially where it passes under the proximal edge of the superficial supinator
muscle (Verhaar & Spaans, 1991)

WHAT ARE WE LOOKING FOR? CONT


Pain aggravated by use of extremity
Pain at lateral epicondylitis
Motor may be weakness present, not always
Pain on resisted supination (Verhaar & Spaans, 1991)

DIFFERENTIAL DIAGNOSIS
POSTERIOR INTEROSSEOUS NERVE SYNDROME (PINS)
Chief complaint: Paralysis or marked weakness of finger or wrist extensors (Barnum et al, 1996)
Weakness and pain in anterior elbow for 12-72 hours with progressive weakness secondary to possible tumor
May be due to:
Compression secondary to bursa enlargement (Barnum et al, 1996)
Repetitive supination/pronation (Barnum et al, 1996)
Lipoma (Verhaar & Spaans, 1991)
Rheumatoid disease (Verhaar & Spaans, 1991)
Hemangioma in radial recurrent vessels (Verhaar & Spaans, 1991)
Aneurysms (Barnum et al, 1996)
Tumors (Barnum et al, 1996)
Fractures about the elbow/proximal forearm (Barnum et al, 1996)

(Barnum et al, 1996)


(Verhaar & Spaans, 1991)

PINS CONTINUED
Motor weakness
Painless with varying degrees of motor loss
Complete PINS palsy, patient will be able to extend the wrist, but only if positioned in
radial deviation. However, they will be unable to extend the MCP joints of all digits but
can extend the PIP and DIP because ulnar nerve innervation to intrinsic hand muscles
(Barnum et al, 1996)

LATERAL EPICONDYLITIS
Presents also as lateral proximal forearm
pain
tennis elbow
Palpation described in previous slide
helps rule in/out lateral epicondylitis
Radial tunnel block injection helps
differentiate RTS vs. lateral epicondylitis

(Barnum et al, 1996)

PHYSICAL EXAMINATION
Identify points of tenderness:
Gentle palpation 5cm distal to lateral epicondyle where nerve enters arcade of Frohse
Continue palpation distal and posterior towards head of supinator

Special Test:
Middle finger extension test patient resists volar directed force applied to dorsum of middle
finger with elbow extended and pronation
Resisted supination Elbow must be positioned in full elbow extension to negate biceps brachii
supination action
Positive tests will reproduce pain in maximal tenderness locations as previously described!

To confirm diagnosis, PT may refer to physician to perform a radial tunnel block injection
(Barnum et al, 1996)

TREATMENT
Splints may be made
Hand therapy
Radial tunnel slide exercises stretching of the extensors

Patient education!
Job modification, alter repetitive activities or vulnerable positions
Very important for road to recovery and to negate surgical intervention

Surgical intervention
Release of Arcade

(Barnum et al, 1996)

REFERENCES
Verhaar J, Spaans F: Radial tunnel syndrome: An investigation of compression neuropathy
as a possible cause. J Bone Joint Surg 73:539544, 1991.
Barnum, M., Mastey, R.D., Weiss, A.C., Akelman, E. (1996). Radial tunnel syndrome. The
Painful hand, 12, 4.