Radial Tunnel Syndrome
Reading time: 5 minutes
Earlier estimates suggested that over ten percent of patients diagnosed with tennis elbow don’t merely have tennis elbow. Now, a new study suggests that number may be much higher.
"63.2% of limbs with lateral epicondylitis were noted to have an associated sensory disturbance of the superficial radial nerve [i.e., radial tunnel syndrome]." (45)
Radial tunnel syndrome can mimic or coexist with lateral epicondylitis. Recognizing that presentation can be the difference between clinical success and failure.
This week’s blog and video share seven practical skills that can help you nail the diagnosis of radial tunnel syndrome and provide the most effective management. In five minutes, you’ll learn the essential skills for successfully managing radial tunnel syndrome.
1. What Is Radial Tunnel Syndrome?
Short answer: Irritation or compression of the radial nerve in the dorsal forearm.
Deeper dive: The radial tunnel is defined as the space surrounding the radial nerve as it traverses the posterior forearm from the radiocapitellar joint thru the supinator muscle. Radial tunnel syndrome describes symptoms generated from irritation or compression of the radial nerve within this short tunnel.
Multiple potential compression sites in the radial tunnel may affect the sensory branch of the radial nerve, the motor branch (also called the posterior interosseous nerve), or both. (2) The most common site of compression within the radial tunnel is beneath a thickened, fibrous proximal edge of the supinator muscle, also called the Arcade of Frohse. This thickening is thought to be developmental due to repetitive strain and is present in 30-80% of the population. (3,4,31)
2. What Are the Symptoms of Radial Tunnel Syndrome?
Short answer: Pain or paresthesia in the dorsal forearm, often mimicking tennis elbow.
Deeper dive: Radial tunnel syndrome symptoms depend on whether irritation affects the sensory branch, motor branch, or both.
Compression or irritation of the superficial sensory branch results in pain, paresthesia, or diminished sensitivity along the dorsal aspect of the forearm, sometimes radiating to the hand, including the first web space and back of the thumb and index finger. (11) These symptoms are often described as deep, aching, and diffuse and frequently mimic lateral epicondylopathy. (12)
Compression of the posterior interosseous nerve (motor branch) manifests as weakness of metacarpophalangeal joint extension and thumb extension, also called “finger drop.” (2) Wrist extension is generally not affected as noticeably because of cross-innervation.
3. What Are the Causes of Radial Tunnel Syndrome?
Short answer: Radial tunnel syndrome causes typically include repetitive microtrauma.
Deeper dive: Radial tunnel syndrome is common in manual laborers and is thought to result from overuse. (27,28)
Forceful handgrip work
Excessive wrist extension, pronation, or supination
Vibration
4. Is There a Test for Radial Tunnel Syndrome?
Short answer: Useful radial tunnel syndrome tests include the radial nerve test and the middle finger test for radial tunnel syndrome.
Deeper dive: Consider the following cluster of radial tunnel assessments:
Radial tunnel compression test - Deeply palpating and rolling your fingers over the radial nerve four finger breaths distal to the lateral epicondyle should provoke symptoms (13)
Middle finger test - Reproduction of radial nerve pain during resisted middle finger extension suggests compression of the radial nerve by the extensor carpi radialis brevis. This test may also be positive in lateral epicondylitis, but radial tunnel irritation is the likely diagnosis when this test is more painful than passively flexing the fingers and wrist of an extended elbow. (13)
Window Test - Radial deviation of the wrist during wrist extension with the forearm pronated may be the most sensitive indicator of posterior interosseous nerve palsy. (33)
Radial nerve test - Neurodynamic tensioning of the radial nerve will often provoke symptoms.
Pro Tip - Don’t forget the basics. Seventy percent of patients with lateral elbow pain demonstrate symptoms or positive clinical findings in the cervical or upper thoracic regions. Positive findings include limited range of motion in flexion and extension and positive provocation testing. (15)
5. How Do You Differentiate Radial Tunnel Syndrome Vs Tennis Elbow?
Short answer: Three P’s: peak tenderness, paresthesia, provocative maneuvers.
Deeper dive: Evidence-based chiropractors are well suited to recognize and manage lateral elbow pain. However, we often jump to the most likely diagnosis of lateral epicondylopathy within seconds of hearing the patient’s history. However, as mentioned earlier, not all pain near the lateral epicondyle is merely tennis elbow. The following chart outlines the difference between tennis elbow and radial tunnel syndrome: (35-38,46)
6. How Do You Treat Radial Tunnel Syndrome?
Short answer: Conservative chiropractic care.
Deeper dive: What is the best radial tunnel syndrome treatment? Last week the HAND Journal concluded that surgeons often struggle with non-operative radial tunnel patients:
“Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis.” (46)
However, these cases often respond successfully to conservative care. (22) Research supports several conservative chiropractic tools:
Neurodynamics - Nerve flossing is thought to enhance the neurodynamic flexibility of a nerve by releasing adhesions. Radial nerve flossing has shown benefits for lateral elbow pain patients. (34). Research has shown that radial nerve flossing can ease pain and improve outcomes for lateral elbow pain patients. (8) Watch this radial nerve floss tutorial video to see how.
Pro Tip: Want to learn more about nerve tension tests and nerve glide exercises? Check out this upper extremity neurodynamics tutorial for a complete synopsis.
Soft tissue manipulation – STM is a valuable tool for managing radial tunnel syndrome. Good clinical judgment is required to assess the point at which the benefits of soft tissue mobilization outweigh the risks of symptom exacerbation. When the symptoms are no longer acute, stretching and myofascial release techniques should be directed at the supinator, brachioradialis, and wrist extensors, including the extensor carpi radialis brevis.
Spinal manipulation -A 2020 JMMT study by Rosedale suggested that up to 44% of elbow pain may arise from an asymptomatic spine. (40) Earlier research found that cervical and thoracic manipulation was a potent treatment tool for lateral elbow pain. (41)
Modalities - Ice, ice massage, electrotherapy, and ultrasound may provide benefits.
Radial tunnel syndrome brace - Angry nerves don’t appreciate compression. So, a tennis elbow counterforce brace, commonly used in the treatment of lateral epicondylitis, will likely aggravate the symptoms of radial tunnel syndrome. (43)
7. How Do You Prescribe the Best Radial Tunnel Syndrome Exercises & ADL Recommendations?
Short answer: Create a ChiroUp Radial Tunnel Syndrome condition report in 4 clicks.
Deeper dive: We made this one crazy simple. Watch this 1-minute video to learn how to make completely customizable reports like this for more than 100 diagnoses.
Like what you see? You can immediately start creating reports like these for your patients in less than 4 clicks!
Did you like what you just learned? Now that you have learned these seven practical tools that you can use for Radial Tunnel Syndrome, it’s time to sharpen your clinical skills for another 100+ conditions with ChiroUp. We’ll help you stay up-to-date with the latest research, treatments & exercises for 100+ conditions—all within one easy-to-use platform. If you aren’t yet a subscriber, get started today!
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