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Some estimates suggest that over ten percent of patients diagnosed with tennis elbow don’t have tennis elbow. Radial tunnel syndrome can mimic or even coexist with lateral epicondylitis, and recognizing this presentation will afford better clinical outcomes.

This week’s blog shares seven practical skills that can help you nail the diagnosis of radial tunnel syndrome and provide the most effective management.

1. Always Suspect Radial Tunnel Syndrome (RTS) 

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. Unfortunately, not all pain near the lateral epicondyle is merely tennis elbow. The following clues should raise suspicion for the diagnosis of RTS.

  • Peak tenderness over the lateral epicondyle suggests tennis elbow. However, RTS patients typically demonstrate a slightly more distal site of peak tenderness, four finger breaths distal to the lateral epicondyle. (1)
  • Paresthesia or diminished sensitivity (along the dorsal aspect of the forearm, sometimes radiating to the hand, first webspace, or back of the thumb and index finger) is common in RTS, but not lateral epicondylopathy. (2) 
  • Nocturnal pain is more common in radial tunnel patients than in those with lateral epicondylopathy. (3)
  • True motor weakness in wrist extension, metacarpal phalangeal joint extension, or thumb extension can occur in significant cases of RTS but not isolated lateral epicondylopathy. (4)

Radial Tunnel

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 two-inch tunnel.

2. Use the Middle Finger Sign

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. (1)

3. The Window Test Can Identify Radial Nerve Palsy

Compression of the radial nerve’s superficial sensory branch results in purely sensory symptoms, while compression of the posterior interosseous nerve produces motor weakness of the finger, hand, and wrist extensors.

Earlier this month, the World Neurosurgery Journal concluded that radial deviation of the wrist during wrist extension with the forearm pronated (aka Window test) might be the most sensitive indicator of posterior interosseous nerve palsy. (5)

4. SMT May Help Ease Lateral Elbow Pain

A 2020 JMPT study by Rosedale suggested that up to 44% of elbow pain may arise from an asymptomatic spine. (6) Earlier research found that cervical and thoracic manipulation was a potent treatment tool for lateral elbow pain. (7) So don’t skip the basics!

5. Radial Nerve Flossing Is Valuable

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.

Want to learn more about nerve tension tests and nerve glide exercises? Check out this upper extremity neurodynamics tutorial for a complete synopsis.

6. Avoid Counterforce Braces for Radial Tunnel Syndrome 

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. (9)

7. Provide Practical ADL Advice 

Sleep position is a possible aggravating factor that delays the healing of an acute injury and may trigger or perpetuate chronic lateral elbow pain. (10) In particular, sleeping with the affected elbow beneath a pillow may result in sustained compression to the wrist extensors and radial nerve. So, teach your patients to keep their arms at their sides to minimize compression. 

Did you like what you just learned? Now that you have mastered 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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  1. Lister G. The Hand: Diagnosis and Indications. 1984, New York, Churchill Livingstone.
  2.  Kirici Y, Irmak MK. Investigation of two possible compression sites of the deep branch of the radial nerve and nerve supply of the extensor carpi radialis brevis muscle. Neurologia medico-chirurgica. 2004;44(1):14-9. Link
  3. Hammer W. Is it Tennis Elbow or Radial Tunnel? Dynamic Chiropractic – December 29, 1997, Vol. 15, Issue 26
  4. Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. American Journal of Roentgenology. 2010 Sep;195(3):585-94. Link
  5. Hanna AS, Omuro PM, Hutchinson JR, Fofana ML, Hellenbrand DJ. The Window Test: a simple bedside method to detect radial deviation of the wrist commonly seen in posterior interosseous nerve palsy. World Neurosurgery. 2021 Nov 7. Link
  6. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30. Link
  7. Vicenzino B, Cleland JA, Bisset L. Joint manipulation in the management of lateral epicondylalgia: a clinical commentary. Journal of Manual & Manipulative Therapy. 2007 Jan 1;15(1):50-6. Link
  8. Arumugam V, Selvam S, MacDermid JC. Radial nerve mobilization reduces lateral elbow pain and provides short-term relief in computer users. The open orthopaedics journal. 2014;8:368. Link
  9. MD Guidelines. Radial Nerve Entrapment. July 2013 Link
  10. Gorski JM. Evaluation of Sleep Position for Possible Nightly Aggravation and Delay of Healing in Tennis Elbow. JAAOS Global Research & Reviews. 2019 Aug;3(8). Link

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