[ case report ]

SHOUTA KANEKO, OT, MSc1 • HIROSHI TAKASAKI, PT, MSc2

Forearm Pain, Diagnosed

as Intersection Syndrome,
Managed by Taping: A Case Series
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I
ntersection syndrome, an overuse injury affecting the forearm, has the APL and EPB, and those of the ECRL
been reported in sporting activity involving the upper limb, such and ECRB; the second may be stenosis,
due to entrapment within the second
as rowing, canoeing, racket sports, weight lifting, and skiing.16
dorsal compartment that houses the
People who have intersection syndrome report pain, crepitus, ECRL and ECRB.4,10,20 Aso et al1 argued
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and/or swelling in the dorsal forearm, 4 to 8 cm proximal to Lister’s in support of the former mechanism,
tubercle,4 where the muscle bellies of the abductor pollicis longus due to the presence of pain on palpation
(APL) and extensor pollicis brevis (EPB) cross the underlying extensor and crepitus over the intersection of the
APL and EPB, and the ECRL and ECRB,
carpi radialis longus (ECRL) and exten- syndrome is uncertain, but 2 potential rather than the distal area of the second
sor carpi radialis brevis (ECRB).5 The mechanisms are considered. The first dorsal compartment, and due to thumb
pathophysiological basis for intersection may be friction between the tendons of movements that accompany crepitus. A
key feature of intersection syndrome on
magnetic resonance imaging (MRI) is
TTSTUDY DESIGN: Case series. plete elimination of crepitus with the application of
Journal of Orthopaedic & Sports Physical Therapy®

peritendinous edema around the first

TTBACKGROUND: Intersection syndrome is an
overuse injury of the forearm. Taping has been de-
scribed for the management of soft tissue injuries,
yet there has been no report for the management
of intersection syndrome using this method. The
purpose of this case series was, therefore, to
describe the efficacy of taping for the management
of intersection syndrome.
TTCASE DESCRIPTION: Five patients with inter-
section syndrome were managed by taping, in an
effort to reduce crepitus induced by thumb move-
ments. Nonstretch sports tape was applied, with
an ulnarly directed tension force across the dorsal
aspect of the forearm. Taping was performed daily
for 3 weeks. Follow-up took place at 1, 2, 3, and 4
weeks, and at 1 year from the initial consultation.
TTOUTCOMES: All patients demonstrated com-
tape. Crepitus induced by wrist movements, ten-
derness over the dorsal forearm, and swelling were
no longer present at 3-week follow-up. Disability
identified by the disability/symptom subscale of
the Disabilities of the Arm, Shoulder and Hand
questionnaire decreased at 3-week follow-up,
and this reduction was maintained at 4-week and
1-year follow-ups.
TTDISCUSSION: Taping improved symptoms and
function in this small case series. One possible
explanation for this improvement may be the
alteration of soft tissue alignment.
TTLEVEL OF EVIDENCE: Therapy, level 4.
J Orthop Sports Phys Ther 2011;41(7):514-519,
Epub 6 April 2011. doi:10.2519/jospt.2011.3569
TTKEY WORDS: overuse syndrome , tape,
thumb, wrist
and second extensor compartment ten-
dons, which extends proximally from the
intersection between the APL and EPB,
and the ECRL and ECRB.4,14
Current management of intersection
syndrome comprises a combination of
rest, nonsteroidal anti-inflammatory
drugs, and splinting.10,16 One report in-
dicated that 60% of patients responded
to this form of management within 2 to
3 weeks.4 However, splinting the wrist
in 15° to 20° of extension restricts wrist
and thumb movements, possibly leading
to difficulty with daily living and work
activities.10 Steroid injection is recom-
mended for those failing to respond to

1
Staff Occupational Therapist, Shinoro Orthopedic, Hokkaido, Japan; PhD candidate, Sapporo Medical University, The Graduate School of Health Sciences, Department of
Occupational Therapy, Hokkaido, Japan. 3PhD candidate, The University of Queensland, School of Health and Rehabilitation Science, Division of Physiotherapy, Queensland,
Australia. The patients reported in this study were seen and treated at the Shinoro Orthopedic. All patients provided informed consent to be included in this case series and their
anonymity was guaranteed. The opinions or assertions contained herein are the private views of the authors. The authors affirm that we have no financial affiliation (including
research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. Address correspondence
to Hiroshi Takasaki, Division of Physiotherapy, School of Health and Rehabilitation Science, The University of Queensland, Brisbane, Queensland 4072, Australia. E-mail:
h.takasaki@uq.edu.au

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 conservative management.10,16
Mulligan15 suggests that tape can be TABLE 1 Demographic Information
used to reduce pain and enhance heal-
ing for Achilles tendinopathy by alter-
Variable Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
ing the direction of forces across the
Age, y 44 50 50 50 53
muscle-tendon unit. If tendon friction
Gender F F F F F
is the predominant cause of intersection
Dominant hand R R R R R
syndrome, as Aso et al1 propose, then the
Painful hand L R R R R
taping technique as described by Mul-
Employment Homemaker Nursing care Nursing care Cleaning Nursing care
ligan across the APL and EPB tendons
Symptom duration, d 90 45 30 14 21
may change the mechanical force around
Crepitus* + + + + +
the painful area, decreasing friction, and
Swelling† + + + + +
resulting in less pain, while assisting
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Tenderness‡
healing processes.
We used the conceptual paradigm
proposed by Mulligan as a new form of
management for intersection syndrome.
The purpose of this case series is to de-
scribe the use of tape for the management
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
+ + + + +
Abbreviations: +, present; F, female; L, left; R, right.
*Crepitus induced by thumb movements.
†
Swelling was visually estimated from a comparison with the opposite side.
‡
Tenderness was present based on pressure pain over the dorsal forearm rated at 3 or more on an
11-point numeric rating scale (0, no pain; 10, pain as bad as it could possibly be).

of intersection syndrome in 5 patients.

Range of Motion of the MCP Joint
TABLE 2
CASE DESCRIPTIONS of the Thumb and the Wrist Joint*

F
ive female patients (mean age, Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
49.4 years), referred to physiother- Active MCP flexion 40° (55°) 45° (55°) 45° (60°) 45° (60°) 40° (60°)
apy with a diagnosis of intersection Passive MCP flexion 45° (55°) 45° (55°) 50° (60°) 50° (60°) 50° (60°)
syndrome, were managed with taping. Active wrist extension 45° (70°) 50° (65°) 50° (70°) 60° (70°) 55° (70°)
The right arm was symptomatic in 4 Passive wrist flexion 60° (85°) 65° (85°) 60° (90°) 70° (90°) 60° (90°)
Journal of Orthopaedic & Sports Physical Therapy®

and the left arm in 1 of the patients. Pa-
tient demographics are summarized in
TABLE 1. These data include duration and
predominant side of symptoms, presence
of crepitus induced by active wrist move-
ments, swelling along the course of the
affected tendons, and tenderness over the
dorsal forearm for each patient. Pain at
rest and raised skin temperature were not
seen in any of the patients.
An orthopaedic surgeon diagnosed
intersection syndrome, based on physi-
cal assessments, including Finkelstein’s
test, isometric muscle testing of the APL,
EPB, ECRL, and ECRB, Tinel’s sign, up-
per limb neurodynamic tests, and the
overall clinical presentation (tenderness
over the dorsal forearm, 4 to 8 cm proxi-
mal to the wrist joint, crepitus induced
by active wrist movements, and visible
swelling along the course of the affected
tendons). Diagnosis was also made with
MRI, by identifying peritendinous ede-
ma around the first and second extensor
Abbreviation: MCP, metacarpalphalangeal.
*Range of motion on the pain-free side provided in parentheses.
compartment tendons, extending proxi-
mally from the intersection between the
APL and EPB, and the ECRL and ECRB.4
All patients in this case series had re-
quested not to be treated with a hand
splint, due to the hindrance of the splint
for their work. Consequently, the patients
were deemed suitable for a trial of taping,
and volunteered for this intervention af-
ter being informed of the available treat-
ment options.
All patients demonstrated limited
range of motion for active and passive
flexion at the metacarpalphalangeal
(MP) joint of the thumb, passive wrist
flexion, and active wrist extension, as
measured by a goniometer (TABLE 2). Fin-
kelstein’s test was positive in each case.
Finkelstein’s test is most commonly as-
sociated with De Quervain’s disease; but
other instances of radial-sided wrist and
distal forearm pain, such as intersection
syndrome, wrist injuries, and entrap-
ment neuropathy of the superficial radial
nerve, can be provoked by the Finkel-
stein’s test maneuver.9,12 However, pain
was also provoked by isometric muscle
testing of the ECRL or ECRB, but not for
the APL or EPB, suggesting the presence
of intersection syndrome rather than De
Quervain’s disease. 3 Furthermore, ten-
derness was found on the dorsal forearm
rather than along the radial aspect of the
wrist,6 which is a clinical picture differ-
ent from that of De Quervain’s disease.
Moreover, crepitus during active thumb
movements was found on the intersec-
tion between the APL and EPB, and the
ECRL and ECRB, on the dorsal forearm,
in contrast to crepitus found over the first
dorsal compartment or at the styloid pro-
cess of the radius in individuals with De

journal of orthopaedic & sports physical therapy  |  volume 41  |  number 7  |  july 2011  |  515

41-07 Kaneko.indd 515 6/15/2011 3:16:55 PM

 [ case report ]
Taping Technique
Most Painful Activity, Pain Intensity  
A generic, 50-mm-wide nonstretch tape
During This Activity, and Functional  
TABLE 3 (Battlewin C50F; Nichiban Co, Ltd, To-
Outcome Score Prior to the Application  
kyo, Japan) was utilized in this study.
of Taping at the Initial Consultation
The taping direction for each patient was
determined by assessing crepitus during
Patient Most Painful Activity Pain During the Activity* DASH-JSSH Disability/Symptom†
thumb movements, while manual force
1 Squeezing 9 59.2
was applied across the soft tissue of the
2 Transferring 8 46.7
dorsal aspect of the forearm. A reduction
3 Transferring 9 67.8
of crepitus, when force was applied in ei-
4 Squeezing 10 75.0
ther the ulnar or radial direction, indicat-
5 Cooking 8 70.0
ed a positive response, which determined
Abbreviation: DASH-JSSH disability/symptom, disability/symptom subscale of the Disabilities of the
the taping direction to be used. Tape was
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Arm, Shoulder and Hand questionnaire, Japanese version.

*Measured by an 11-point numeric pain scale (0, no pain; 10, pain as bad as it could possibly be). then applied in an attempt to replicate
†
A high score indicates poor upper limb function. and maintain the manually applied force
across the muscle-tendon unit. The dis-
tal end of the tape was applied first to
the muscle bellies of the APL and EPB.
Tension was exerted with the free end
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of the tape as it was applied across the

dorsal forearm, perpendicular to its long
axis (FIGURE 1). A second layer of tape was
used to reinforce the first layer. Reevalu-
ation of thumb movement was performed
to ensure the effectiveness of the tape in
eliminating crepitus induced by active
thumb movements. If crepitus remained,
the tape direction or tension force was al-
Journal of Orthopaedic & Sports Physical Therapy®

tered slightly until no crepitus was per-

FIGURE 1. Taping over the dorsal forearm with an ulnarly directed tension force. Abbreviations: APL, abductor
pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EPB, extensor pollicis brevis.
Quervain’s disease.3 These findings indi-
cated less possibility of the presence of De
Quervain’s disease. In addition, in each of
our patients, the Tinel’s sign and upper
limb neurodynamic tests suggestive of
entrapment neuropathy of the superficial
radial nerve2,9 were negative.
TABLE 3 summarizes functional dis-
ability for each patient and pain inten-
sity prior to the application of taping at
the initial consultation. Pain intensity
was measured with an 11-point numeri-
cal rating scale (NRS), and functional
scores measured with the disability/
symptom subscale of the Disabilities of
the Arm, Shoulder and Hand question-
naire, Japanese version (DASH-JSSH
disability/symptom), for which reliabil-
ity and validity have been established.11
All patients provided informed consent
for publication and their anonymity was
guaranteed.
ceived. Once the specific taping direction
and tension force were determined, each
patient was instructed in self-application
of the tape.
The tape was removed at night, and
each patient was instructed to maintain
the taping regimen for 3 weeks and al-
lowed to continue work. Patients were
advised to reapply the tape if the effects
of taping were not optimal and to stop
taping if they had any adverse skin reac-
tion, of which there were none during the
treatment period. The patients were also
advised to perform their normal daily
activities. Following the 3-week inter-
vention, all patients were advised to use
the symptomatic limb during activities
of daily living and to work without tape.
They were instructed to reapply the tape
if they had any return of symptoms.
Outcome Measures
Outcome measures included the pres-

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41-07 Kaneko.indd 516 6/15/2011 3:16:57 PM

 ence of crepitus induced by active thumb
The Presence or Absence of Crepitus Induced
movements with no tape application,
by Active Thumb Movements, Swelling, and
tenderness over the dorsal forearm (3 TABLE 4
Tenderness Over the Dorsal Forearm Without
or more on the NRS), swelling, and
Taping at Each Follow-up Point for Each Patient
functional disability as measured by the
DASH-JSSH disability/symptom. As-
Initial
sessments were taken at the initial evalu-
Patient/Measures Consultation 1-wk Follow-up 2-wk Follow-up 3-wk Follow-up 4-wk Follow-up
ation, prior to the initial application of
Patient 1
tape, and at the follow-up points of 1, 2, 3,
and 4 weeks. In addition, 1 year following Crepitus + + + – –

the initial assessment, each patient was Swelling* + + – – –

assessed with the DASH-JSSH disability/ Tenderness †
+ + + – –
symptom via phone interview.
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Patient 2

OUTCOMES Crepitus + + + – –

Swelling + + – – –

I
n all patients, crepitus induced by Tenderness + + + – –
thumb movement was diminished or
Patient 3
reduced by the manual application of
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

an ulnarly directed force on the soft tis- Crepitus + + + – –

sues of the dorsal forearm, as force ap- Swelling + – – – –

plied in the opposite (radial) direction Tenderness + + + – –
produced no change. In addition, crepi-
Patient 4
tus was resolved by taping across the
dorsal forearm with an ulnarly directed Crepitus + + + – –

force in all patients. Movement was less Swelling + – – – –

painful when the tape was applied, and Tenderness + + – – –
all patients reported that the symptom-
Patient 5
Journal of Orthopaedic & Sports Physical Therapy®

relieving effects of taping lasted through-

out the day, making reapplication of the Crepitus + + – – –

tape unnecessary. Swelling + – + – –

At 3-week follow-up, all patients re- Tenderness + + + – –
ported the absence of crepitus induced
Abbreviations: +, present; –, absent.
by thumb movements. In addition, other *Swelling was visually estimated from a comparison with the opposite side.
findings were no longer present, includ- †
Tenderness was present based on pressure pain over the dorsal forearm rated at 3 or more on the
ing swelling and tenderness over the 11-point (0-10) numeric rating scale.

dorsal forearm (TABLE 4). FIGURE 2 demon-

strates the scores on the DASH-JSSH dis-
ability/symptom at each follow-up point
for each patient. There was considerable
improvement in upper limb function at
the 3-week follow-up in all patients, as
tients maintained pain-free normal up-
per limb function at 1-year follow-up.
DISCUSSION
an accurate diagnosis of intersection
syndrome is important to identify those
likely to respond to this form of manage-
ment. In the current case series, a com-
prehensive physical examination and

evidenced by change in DASH-JSSH dis-
ability/symptom scores. At the 4-week
follow-up, the DASH-JSSH disability/
symptom score in each patient was not
different from that of the 3-week follow-
up, and all patients noted neither repro-
duction of pain during functional activity
nor limited range of motion of the thumb
and wrist. Consequently, patients were
discharged from physiotherapy. All pa-
T
his case series suggests the ben-
eficial effects of taping for the man-
agement of intersection syndrome.
It should be noted that the taping tech-
nique reported in this study is unlikely to
be effective for other forearm pain syn-
dromes, such as De Quervain’s disease
and entrapment neuropathy of the su-
perficial radial nerve, due to differences
in underlying pathophysiology. Hence,
MRI were used to establish the diagnosis
of intersection syndrome.
All patients experienced rapid im-
provement of upper limb function with
the application of tape, despite the dura-
tion of symptoms having been present
for up to 90 days in 1 patient. Although
this finding suggests the positive effect of
taping in individuals with intersection
syndrome, a cause-and-effect relation-

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100
90
80
70
60
50
40
30
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20
10
0
Initial Consultation 1-wk Follow-up 2-wk Follow-up
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Patient 1 Patient 2
FIGURE 2. Scores on the disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand
questionnaire, Japanese version at each follow-up point for each patient. Scores on the scale range from 0 to 100,
with higher scores indicating greater disability.
ship cannot be established from a case
series. Some studies have demonstrated
a positive effect of taping on pain reduc-
Journal of Orthopaedic & Sports Physical Therapy®
tion,8,17-19 and Mulligan15 suggests that this
positive effect of taping on pain reduction
and soft tissue healing may be related to
the alteration of soft tissue biomechan-
ics. Yet the ability of taping to change the
alignment of anatomical structures is
debatable.13 In the current case series, all
patients experienced reduction of crepi-
tus induced by thumb movements when a
force to shift the skin was applied manu-
ally. This suggests that taping might in-
duce alteration of soft tissue alignment of
the APL, EPB, ECRL, and/or ECRB. Nev-
ertheless, it is uncertain whether taping
actually changes soft tissue alignment,
particularly when these muscles are con-
tracting. MRI evaluation of muscle align-
ment before and during taping would be
necessary to support such a hypothesis.
In addition, 5 is an insufficient number
of patients to clearly establish that an
ulnarly directed force is necessary to ob-
tain reduction or disappearance of the
crepitus in patients with this condition.
518  |  july 2011  |  volume 41  |  number 7  |  journal of orthopaedic & sports physical therapy
41-07 Kaneko.indd 518
[ case report
3-wk Follow-up 4-wk Follow-up 1-y Follow-up
Patient 3 Patient 4 Patient 5
Further studies with bigger sample sizes
would be required to confirm this finding.
All patients demonstrated consider-
able improvement of upper limb function
over the 3-week taping period, as well as
maintenance of upper limb function at
the 1-year follow-up. This indicates the
potential usefulness of taping for the
management of intersection syndrome.
In future clinical studies, it would be in-
teresting to compare the effectiveness of
taping to other treatment approaches,
such as splint therapy and steroid injec-
tion, in terms of time to recovery, cost ef-
fectiveness, quality of life, satisfaction of
treatment, long-term functional ability of
the upper limb, and recurrence rate. For
example, splint therapy restricts normal
wrist/hand movements10 and may lead
to a decrease in quality of life and/or
low satisfaction with treatment. Also, in
the management of shoulder and elbow
tendinitis, steroidal injection has poorer
long-term outcomes in pain and physical
function than conservative treatments
without injection.7 With these consider-
ations, taping may be a useful approach
]
for intersection syndrome.
It should be noted that there may be
more effective taping approaches than
the technique reported here. We did
not compare different methods of tap-
ing, for example, different tape width,
length, and properties (eg, stretch or
nonstretch). These points merit further
investigation to find the optimal applica-
tion of tape in the management of inter-
section syndrome. t
ACKNOWLEDGEMENTS: The authors acknowl-
edge Yoshikazu Ikemoto, MD, PhD for dif-
ferential diagnosis and Toby Hall, PT, MSc,
FACP for reviewing the manuscript prior to
submission.
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Newhouse KE. Patellar taping: a radiographic http://dx.doi.org/10.2519/jospt.2008.2791

examination of the medial glide technique. Am J 18. Vicenzino B, Brooksbank J, Minto J, Offord WWW.JOSPT.ORG
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