Patients › Elbow
Radial Tunnel Syndrome
Radial tunnel syndrome — causes forearm pain, weakness straightening fingers, and is distinct from tennis elbow.
Ang iyong nararamdaman¶
Ang pangunahing sintomas ay sakit sa labas ng iyong forearm, malapit sa iyong siko. Karaniwan itong pinakamatindi sa isang masakit na bahagi na ilang sentimetro sa ibaba ng nakaungos na buto sa labas ng iyong siko. Ang pagpindot sa bahaging iyon ay madalas masakit. Ang sakit ay maaaring kumalat pababa sa likod ng iyong forearm patungo sa iyong pulso.
Pinalalala ito ng ilang partikular na galaw. Ang pagpihit ng iyong palad paitaas habang may pumipigil dito, o ang pagtuwid ng iyong gitnang daliri habang may pumipigil dito, ay maaaring magdulot ng sakit. Ganoon din ang aktibidad na patuloy na nagbibigay-bigat sa iyong forearm. Napapansin ng maraming tao na sumisiklab ang sakit pagkatapos ng trabaho o sports sa halip na habang nagpapahinga.
Ang kondisyong ito ay nakaaapekto sa isang nerve na nagsu-supply sa mga kalamnan sa halip na sa balat. Ibig sabihin, malamang na hindi ka magkakaroon ng pamamanhid o pangingilig, at karaniwang gumagana nang normal ang nerve mismo. Ang problema ay sakit, hindi panghihina o pagkawala ng pakiramdam.
Sa araw-araw, ang sakit ay may tendensiyang lumitaw sa mga gawaing nangangailangan ng paghawak at pagpihit. Ang pagbuhat ng kettle, pagpihit ng door handle, paggamit ng screwdriver o pagpiga ng tela ay maaaring lahat masakit. Dahil ang masakit na bahagi ay nasa malapit sa labas ng siko, ang kondisyong ito ay madalas napagkakamalang tennis elbow, at maaaring magkasabay na mangyari ang dalawa.
Walang iisang test na nakapagkukumpirma sa kondisyong ito. Ginagawa ng iyong surgeon ang diagnosis batay sa iyong salaysay at sa isang pagsusuri, habang tinitingnan ang partikular na masakit na bahaging iyon at ang pattern ng iyong sakit.
Bantayan ang mga senyales na ito. Magpatingin sa iyong GP o humingi ng review mula sa isang espesyalista kung ang iyong mga sintomas ay hindi humuhupa, lumalala sa loob ng ilang linggo, ginigising ka sa gabi, o pumipigil sa iyong magtrabaho o gamitin ang iyong braso. Pumunta sa emergency department sa mismong araw ding iyon kung ang iyong braso ay maging mainit, namumula, namamaga at masakit, lalo na kung may lagnat, o kung ang iyong kamay ay maging maputla, malamig, puti o asul. Kung hindi mo makontak ang klinika pagkatapos ng oras ng trabaho o sa weekend, pumunta sa pinakamalapit na emergency department.
Ano ang aktwal na nangyayari¶
Ang sakit ay nagmumula sa isang nerve, hindi sa elbow joint mismo. Ang nerve ay isang kable na nagdadala ng mga signal sa pagitan ng iyong utak at ng iyong mga kalamnan. Isang sangay ng radial nerve ang dumadaan pababa sa labas ng iyong forearm, lampas sa siko, upang mag-supply sa mga kalamnang nagtutuwid ng iyong pulso at mga daliri.
Sa kahabaan ng bahaging iyon, ilang magkakahiwalay na istruktura ang nakapuwesto malapit sa nerve. Ang gilid ng isang kalamnan, isang fibrous na banda, o isang maliit na grupo ng mga tumatawid na blood vessel ay maaaring isa-isang dumiin dito. Hindi ito iisang makitid na daanan. Mas katulad ito ng isang daanang panlakad na may ilang posibleng lugar ng pagkaipit sa kahabaan nito, kung saan ang alinman ay maaaring pumitpit sa kableng dumadaan sa tabi nito.
Kapag dumiin sa nerve ang isa sa mga istrukturang iyon, naiirita at sumasakit ang nerve. Iyan ang dahilan kung bakit ang sakit ay nasa isang masakit na bahagi sa ibaba ng nakaungos na buto sa labas ng iyong siko, at kung bakit lumalala ito kapag pinipihit mo ang iyong palad paitaas o itinutuwid ang iyong gitnang daliri habang may pumipigil dito. Hinihila ng mga galaw na iyon ang mga kalamnang sinu-supply-an ng nerve na ito, at nagrereklamo ang iritadong nerve.
Gumagana pa rin ang nerve, kaya patuloy na gumagana ang iyong mga kalamnan at wala kang nararamdamang pamamanhid o pangingilig. Ang problema ay iritasyon at sakit, hindi pagkawala ng signal. Dahil napakalapit ng masakit na bahagi sa labas ng siko, madaling mapagkamalan ang sakit bilang tennis elbow, na nakaaapekto sa isang tendon sa parehong lugar. Maaari pa ngang magkasabay na mangyari ang dalawa.
Ano ang maaari naming gawin tungkol dito¶
Si Dr Kieran Hirpara, isang upper-limb surgeon sa Mater Private Hospital Rockhampton, ay nagsisimula sa mga opsyon na hindi gaanong invasive na angkop sa iyong kondisyon. Ang mga pasyente ay karaniwang nirerefer sa aming klinika ng kanilang GP; kung iminungkahi ng isang physiotherapist na magpatingin sa amin, kakailanganin mo pa rin ng referral mula sa iyong GP upang maging eligible para sa Medicare rebate. Sa klinika, kumukuha kami ng history, sinusuri ang iyong braso, at nagsasaayos ng imaging kung makatutulong ito. Para sa kondisyong ito, karaniwan naming sinusubukan muna ang non-operative care, at isinasaalang-alang ang operasyon kapag hindi ito nagbigay ng sapat na pagbuti.
Ang unang hakbang ay ang pagbabago sa paraan ng paggamit mo ng iyong braso. Ang pagbabawas sa mga gawaing may paghawak at pagpihit na nagpapasiklab ng sakit ay nagbibigay ng pagkakataon sa iritadong nerve na kumalma. Layunin ng hand therapy na pahupain ang sakit at muling buuin ang kakayahan mong bigyan ng bigat ang forearm, upang muling maging komportable ang trabaho at mga pang-araw-araw na gawain. Hinihiling namin na bigyan mo ito ng sapat na pagsubok bago isaalang-alang ang anumang susunod na hakbang.
Ang gamot sa sakit at mga anti-inflammatory ay makatutulong sa iyo sa panahon ng pagsiklab. Pinahuhupa nila ang pananakit habang gumagana ang iba pang mga hakbang. Hindi nila inaayos ang pagkaipit ng nerve mismo.
Kung hindi nagbigay ng sapat na pagbuti ang non-operative care, opsyon ang operasyon. Ang operasyon ay tinatawag na radial tunnel release. Gumagana ito sa pamamagitan ng pagpapalaya sa nerve sa bawat lugar kung saan dumidiin dito ang isang kalapit na istruktura. Bago ito irekomenda, maingat naming sinusuri kung saan naiipit ang nerve, upang tamaan ng operasyon ang tamang lugar at magalaw ang pinakakaunting nakapaligid na tissue hangga't maaari. Dahil ang diagnosis ay nakasalalay sa iyong salaysay at pagsusuri sa halip na sa iisang malinaw na test, itinuturing namin ang desisyong mag-opera bilang isang desisyong pinagsasaluhan, na ginagawa nang magkasama kapag naunawaan mo na kung ano ang kaya at hindi kayang pahupain ng operasyon.
Ano ang dapat asahan¶
Para sa karamihan ng mga tao, hindi napipinsala ng kondisyong ito ang nerve. Patuloy na gumagana ang nerve, kaya patuloy na gumagana ang iyong mga kalamnan at hindi ka nawawalan ng pakiramdam. Ang problema ay sakit, at ang sakit mula sa iritadong nerve ay maaaring matagal bago humupa. Bihira itong mawala nang magdamag, at madalas itong sumisiklab sa mga gawaing may paghawak at pagpihit bago ito gumaan.
Ang tapat na larawan ay mahirap hulaan ang kondisyong ito. Ang ilang tao ay gumagaan sa pamamagitan ng pahinga, pagbabago sa aktibidad at hand therapy. Ang iba ay patuloy na nagkakaroon ng sakit sa kabila ng mahusay na non-operative care. Walang maaasahang test upang kumpirmahin ang diagnosis, kaya mas mahirap sabihin nang maaga kung saang grupo ka mapapabilang. Ang masasabi namin ay ang sakit ay may tendensiyang dumating at umalis depende sa kung gaano kalaking bigat ang ibinibigay mo sa iyong forearm, sa halip na tuloy-tuloy na lumalala.
Kung gumana ang non-operative care, unti-unting gumagaan ang sakit sa loob ng ilang linggo hanggang ilang buwan habang nababawasan ang iritasyon ng nerve. Inaasahan mong unang hindi gaanong sasakit ang mga pang-araw-araw na gawain tulad ng pagbuhat ng kettle o pagpihit ng door handle, bago maging normal muli ang mas mabibigat na trabaho. Kung isinagawa ang operasyon pagkatapos na hindi sapat na nakatulong ang non-operative care, unti-unti rin ang paggaling sa halip na biglaan, at ang ilang tao ay mayroon pa ring kaunting sakit pagkatapos.
Kung pababayaan ang kondisyon, maaari itong kusang humupa, ngunit maaari rin itong magpatuloy o patuloy na sumiklab tuwing babalik ka sa mga gawaing nagpapalala nito. Walang paraan upang malaman nang maaga kung alin ang mangyayari. Ang karaniwang mahalaga ay bigyan ng sapat na pagsubok ang paggamot at huwag ipilit ang sarili sa sakit na hindi humuhupa.
Kung ang iyong mga sintomas ay hindi humuhupa, lumalala sa loob ng ilang linggo, ginigising ka sa gabi, o pumipigil sa iyong magtrabaho o gamitin ang iyong braso, magpatingin sa iyong GP o humingi ng review mula sa isang espesyalista. Pumunta sa emergency department sa mismong araw ding iyon kung ang iyong braso ay maging mainit, namumula, namamaga at masakit, lalo na kung may lagnat, o kung ang iyong kamay ay maging maputla, malamig, puti o asul. Kung hindi mo makontak ang klinika pagkatapos ng oras ng trabaho o sa weekend, pumunta sa pinakamalapit na emergency department.
Kailan dapat magpatingin¶
Ang mga babalang senyales para sa kondisyong ito ay tungkol sa sakit na hindi humuhupa, hindi tungkol sa panganib. Magpatingin sa iyong GP o humingi ng review mula sa isang espesyalista kung hindi humupa ang sakit sa iyong forearm pagkatapos ng sapat na pagsubok ng pahinga at pagbabago sa aktibidad, o kung patuloy ka nitong pinipigilang magtrabaho o gamitin ang iyong braso. Magpatingin nang mas maaga kung kapansin-pansin ang masakit na bahagi sa ibaba ng labas ng iyong siko, o kung palaging nagdudulot ng sakit ang pagpihit ng iyong palad paitaas o ang pagtuwid ng iyong gitnang daliri habang may pumipigil dito. Ang mga pattern na ito ay nagtuturo sa kondisyong ito sa halip na sa tennis elbow, at nararapat itong masuri nang maayos.
Karaniwang hindi napipinsala ng kondisyong ito ang nerve, kaya ang biglaang panghihina ng iyong pulso o mga daliri ay hindi karaniwang bahagi nito. Kung mapansin mo ang bagong panghihina sa pagtuwid ng iyong pulso, mga daliri o hinlalaki, humingi kaagad ng review mula sa isang espesyalista sa halip na maghintay, dahil ang pattern na iyon ay nagpapahiwatig ng ibang problema sa nerve na sinusuri ayon sa sarili nitong timeline.
Pumunta sa emergency department sa mismong araw ding iyon kung ang iyong braso ay maging mainit, namumula, namamaga at masakit, lalo na kung may lagnat, o kung ang iyong kamay ay maging maputla, malamig, puti o asul. Kung hindi mo makontak ang klinika pagkatapos ng oras ng trabaho o sa weekend, pumunta sa pinakamalapit na emergency department.
Higit pang detalye¶
Advanced reading: the deeper science (optional)
Ang seksyong ito ay higit pa sa kailangan mo para sa iyong sariling mga desisyon sa paggamot. Ang radial tunnel syndrome ay karapat-dapat sa karagdagang pagbabasa sa isang hindi komportableng dahilan: ito ang kondisyon sa site na ito na may pinakamahinang basehan ng ebidensya, walang pagsusuri na nakakapagkumpirma nito, at ang malinaw na pagsasabi kung gaano ito kawalang-katiyakan ay dapat maging bahagi ng anumang desisyon na operahan.
Walang confirmatory test¶
Karamihan sa mga nerve compression ay maaaring mapatunayan. Ang carpal tunnel syndrome ay nagdudulot ng slowed conduction sa wrist; ang cubital tunnel naman ay sa elbow. Ang radial tunnel syndrome ay karakteristikong hindi nagdudulot nito, ang sangay ng nerve na sangkot ay nagsu-supply sa muscle sa halip na sa balat, kaya walang numbness na maaaring i-map, at ang mga nerve conduction study ay madalas na normal.
Samakatuwid, ang diagnosis ay nakadepende sa pattern ng sakit, tenderness ilang sentimetro distal sa lateral epicondyle sa halip na sa ibabaw nito, at ang tugon sa isang local anaesthetic block. Ang bawat isa sa mga ito ay suggestive; wala sa mga ito ang definitive. Inilalarawan ng mga contemporary review ang patuloy na kontrobersya tungkol sa parehong diagnosis at outcomes [1].
Ang praktikal na kahihinatnan nito ay ang mataas na rate ng pagkalito sa tennis elbow, na matatagpuan sa katabi nito at maaaring magkasabay na mangyari. Ang persistent na "tennis elbow" na hindi tumugon sa mabuting paggamot ay isa sa mga pinakakaraniwang sitwasyon kung saan ang radial tunnel syndrome ay kalaunang isinasaalang-alang.
Ang ebidensya para sa paggamot nito ay tunay na kakaunti¶
Isang systematic review ng mga interbensyon ang nakatagpo ng tendensya na ang surgical decompression ay maaaring maging epektibo, at, ang mas kapansin-pansing natuklasan, na ang pagiging epektibo ng mga conservative treatment ay hindi alam, dahil para sa karamihan sa mga ito ay walang available na mga pag-aaral [2].
Hindi ito ang karaniwang pormulasyon na "limitado ang ebidensya." Para sa karamihan ng mga non-operative treatment na inaalok para sa kondisyong ito, ang mga pag-aaral ay hindi pa nagagawa. Ang mga kasalukuyang review ay inuuna pa rin ang non-surgical management, kung saan ang decompression ay isang viable option para sa mga refractory case [1], at ang pagkakasunod-sunod na iyon ay sumasalamin sa makatwirang pag-iingat sa halip na napatunayang superiority.
Ano ang ibig sabihin nito para sa isang desisyon¶
May dalawang bagay na kasunod, at magkasalungat ang mga ito.
Laban sa maagang operasyon: hindi makukumpirma ang diagnosis, kaya ang operasyon ay maaaring mag-decompress ng isang nerve na hindi naman ang pinagmumulan ng problema. Sa mga kaso kung saan nabigo ang decompression, madalas na imposibleng matukoy kung ang operasyon ba ay hindi sapat o kung mali ang diagnosis.
Para sa pagsasaalang-alang nito sa tamang pasyente: wala ring evidence base na sumusuporta sa mga alternatibo, kaya ang paghihintay ay hindi ang opsyon na may suporta ng ebidensya gaya ng inaakala ng mga tao. Ito ay simpleng mas mababa lamang ang panganib.
Ang makatwirang posisyon ay ang isang kumpirmadong diagnosis ay mas mahalaga rito kaysa sa alinmang bahagi ng site na ito, isang consistent na history, pagsusuring nagtuturo sa radial tunnel sa halip na sa epicondyle, imaging na nag-eexclude ng space-occupying lesion, at ideally, isang kapani-paniwalang tugon sa isang diagnostic block bago gumawa ng isang irreversible na hakbang.
Isang kaugnay ngunit magkaibang problema¶
Ang posterior interosseous nerve palsy, ang panghihina ng extension ng mga daliri at thumb sa halip na pananakit, ay isang natatanging entity na may mas malinaw na pamamahala. Kung saan ang imaging ay hindi nagpapakita ng compressive lesion, dapat munang subukan ang conservative management, at ang surgery ay nakalaan lamang para sa mga napatunayang compressive lesions at para sa pagkabigo ng conservative treatment [3]. Kung walang space-occupying lesion, iminumungkahi ang pagsubok ng non-operative management, at inirerekomenda ang exploration kung walang senyales ng muscle recovery pagkatapos ng 6 na linggo ng obserbasyon, o kung ang panghihina ay progresibo [4].
Ang mga ito ay mga konkretong threshold, at ang pagkakaroon ng mga ito ang pinakamalinaw na ilustrasyon ng kaibahan: kapag ang nerve ay kitang-kitang huminto sa paggana, kayang sabihin ng literatura kung ano ang gagawin at kailan. Kapag ito ay masakit lamang, hindi nito kaya.
Mga Sanggunian¶
[1] Wolf JM, Patel R, Ghosh K. Radial tunnel syndrome: review and best evidence. J Am Acad Orthop Surg. 2023;31(15):813-9. https://doi.org/10.5435/JAAOS-D-23-00314
[2] Huisstede B, Miedema HS, van Opstal T, de Ronde MT, Verhaar JA, Koes BW. Interventions for treating the radial tunnel syndrome: a systematic review of observational studies. J Hand Surg Am. 2008;33(1):72.e1-72.e10. https://doi.org/10.1016/j.jhsa.2007.10.001
[3] McGraw I. Isolated spontaneous posterior interosseous nerve palsy: a review of aetiology and management. J Hand Surg Eur Vol. 2018;44(3):310-6. https://doi.org/10.1177/1753193418813788
[4] Sigamoney KV, Rashid A, Ng CY. Management of atraumatic posterior interosseous nerve palsy. J Hand Surg Am. 2017;42(10):826-30. https://doi.org/10.1016/j.jhsa.2017.07.026
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview¶
- Radial tunnel syndrome is relatively uncommon but is an important cause of lateral forearm pain [1].
- Clinical examination is a crucial part of the diagnosis of radial tunnel syndrome [1].
- The duration of symptoms averaged 2.3 years before a definitive diagnosis of radial tunnel syndrome was made [2].
- The diagnosis of radial tunnel syndrome remains clinical [5].
- Adherence to a defined protocol is useful in diagnosing radial tunnel syndrome [5].
- The issue surrounding radial tunnel syndrome traditionally has been properly identifying it clinically [7].
- Compression of the radial nerve at the elbow is of moderate frequency compared to the ulnar tunnel syndrome [9].
- A case of bilateral radial tunnel syndrome with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression [6].
- The Rule-of-Nine test effectively specifies the site of tenderness for the diagnosis of radial tunnel syndrome [11].
Anatomy & Pathophysiology¶
Clinical Presentation & Diagnostic Challenges¶
- Radial tunnel syndrome is a relatively uncommon but important cause of lateral forearm pain [1].
- Clinical examination is a crucial component of the diagnosis for radial tunnel syndrome [1].
- The average duration of symptoms before a definitive diagnosis of radial tunnel syndrome was 2.3 years [2].
- Prominent focal tenderness in the area of the radial tunnel is a principal diagnostic criterion for radial tunnel syndrome [20].
- In radial tunnel syndrome, symptoms do not occur in the distribution of the purportedly affected nerve, which distinguishes focal tenderness from a positive Phalen's test in carpal tunnel syndrome [20].
- Skeptics note that radial tunnel syndrome presents with normal neurologic function and no confirmatory electrodiagnostic evidence of nerve dysfunction, contrasting with other well-described entrapment neuropathies [20].
Etiology & Pathophysiology¶
- There is dispute over the etiology of radial tunnel syndrome, with some skeptics questioning its status as a viable entrapment neuropathy [20].
- The posterior interosseous nerve carries unmyelinated (group IV) afferent fibers from the wrist capsule and small myelinated (group IIA) afferent fibers from muscles along its distribution [20].
- Unmyelinated group IV fibers are associated with nociception and pain [20].
- The current best evidence for the conservative management of radial tunnel syndrome consists primarily of expert opinion and inferences from studies on other nerve compressions [3].
Relevant Elbow Anatomy¶
- The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that afford bony stability [63].
- The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [63].
- The radiocapitellar joint is formed by the articulation of the capitellum and radial head [63].
- The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [63].
- The lateral epicondyle is the origin of the lateral extensor musculature [63].
- The radial nerve enters the interval between the brachialis and brachioradialis muscles in the proximal angle of the lateral approach to the elbow [66].
- The deep branch of the radial nerve enters the supinator muscle [66].
- The posterior interosseous nerve is located just superficial to the anterior joint capsule at the level of the radiocapitellar joint [75].
- At the level of the radial neck, the posterior interosseous nerve may come in direct contact with the joint capsule [75].
- Supination increases the linear distance between the posterior interosseous nerve and the radial head [107].
Classification¶
- Radial tunnel syndrome (RTS) and posterior interosseous nerve (PIN) compression are distinct entities with different clinical presentations but share identical potential sites of nerve interference [29].
- The author of [29] proposes unifying RTS and PIN compression as mild and severe forms of one disease to simplify nomenclature [29].
- The authors of [52] recommend viewing radial tunnel syndrome and posterior interosseous nerve syndrome as a single condition presenting along a spectrum of nerve entrapment [52].
- Radial tunnel syndrome is a pain syndrome caused by compression of the posterior interosseous nerve at the proximal forearm [22].
- The diagnosis of radial tunnel syndrome remains clinical, and adherence to a defined protocol is useful in diagnosing this condition [5].
- A differential latency of ≥0.30 ms was considered indicative of radial tunnel syndrome [16].
- Radial tunnel syndrome is an illness construct based on a speculative pathophysiology with no verifiable pathophysiology or accepted reference standard for diagnosis [14].
- Skeptics note that the signs and symptoms of RTS contrast from other well-described entrapment neuropathies in that there is prominent focal tenderness, normal neurologic function, and no confirmatory electrodiagnostic evidence of nerve dysfunction [20].
- Prominent focal tenderness in the area of the radial tunnel remains one of the principal diagnostic criteria for RTS [20].
- Focal tenderness at the radial tunnel in RTS differs from a positive Phalen's test in carpal tunnel syndrome in that the symptoms do not occur in the distribution of the purportedly affected nerve [20].
- There has been no randomized controlled trial that compares surgical with nonsurgical treatment or with a placebo for RTS [20].
- Skeptics of RTS point to the great variability of surgical results reported in the literature as one of the characteristics of placebo surgery [20].
Clinical Presentation¶
- Radial tunnel syndrome is a relatively uncommon cause of lateral forearm pain [1].
- Radial tunnel syndrome and posterior interosseous nerve compression are distinct entities with different clinical presentations [29].
- The author proposes unifying radial tunnel syndrome and posterior interosseous nerve compression as mild and severe forms of one disease to simplify nomenclature [29].
- The authors recommend viewing radial tunnel syndrome and posterior interosseous nerve syndrome as a single condition presenting along a spectrum of nerve entrapment [52].
- Prominent focal tenderness in the area of the radial tunnel is one of the principal diagnostic criteria for radial tunnel syndrome [20].
- In radial tunnel syndrome, symptoms do not occur in the distribution of the purportedly affected nerve, which differs from a positive Phalen's test in carpal tunnel syndrome [20].
- A diagnosis of radial tunnel syndrome should be considered in patients with forearm and wrist pain that has not responded to more conventional treatment [13].
- The diagnosis of radial tunnel syndrome remains clinical, and adherence to a defined protocol is useful in diagnosing the condition [5].
- The issue surrounding radial tunnel syndrome has traditionally been properly identifying it clinically [7].
- A case of bilateral radial tunnel syndrome presented with signs discordant with traditionally used clinical diagnostic tests [6].
- Muscle denervation edema or atrophy along the distribution of the posterior interosseous nerve is the most common MR finding in radial tunnel syndrome [32].
- A symptomatic double-level entrapment of the posterior interosseous branch of the radial nerve has been described [51].
- Compression of the radial nerve at the elbow is of moderate frequency compared to ulnar tunnel syndrome [9].
- The annual incidence rate of posterior interosseous nerve entrapment is estimated to be 0.03% [88].
- The most frequent location of radial nerve entrapment is around the elbow, specifically involving the posterior interosseous nerve branch [88].
- The radial tunnel spans 5 cm, extending from the humero-radial joint and running distally between the deep and superficial heads of the supinator [88].
- The radial tunnel is bounded laterally by extensor carpi radialis longus and extensor carpi radialis brevis muscles and medially by biceps tendon and the brachialis [88].
- The roof of the radial tunnel is formed by brachioradialis [88].
- The floor of the radial tunnel is the elbow-joint capsule [88].
- Potential sites of entrapment in the radial tunnel include capsular tissue of the radiocapitellar joint, hypertrophic crossing branches of leash of Henry, the leading proximal tendinous and medial edge of ECRB, the arcade of Frohse, and the distal border of the supinator between its two heads [88].
- The arcade of Frohse is noted to be the most common site of entrapment in the radial tunnel [88].
- Clinical criteria for radial tunnel syndrome include activity-related pain, maximal tenderness 3–5 cm distal to the lateral epicondyle, pain exacerbation with forearm supination, radiation to the dorsoradial aspect of the forearm, and a positive Lister test [81].
- A clinical diagnosis of radial tunnel syndrome requires 4 of 5 diagnostic signs and symptoms, with one being maximal tenderness 3–5 cm distal to the lateral epicondyle [81].
- Physical examination for radial tunnel syndrome includes wrist flexion and forearm pronation, the Rule of Nines test, and assessment of weakness and pain with resisted long finger extension [86].
- The history for radial tunnel syndrome includes extensor musculature "forearm aching" [86].
Investigations¶
Clinical Diagnosis¶
- A diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment [13].
- It is important to understand the anatomic course and distribution of the radial nerve in order to make an accurate diagnosis [24].
Electrodiagnostic Studies¶
Imaging¶
- Neuroimaging should be considered as a complementary diagnostic method in posterior interosseous neuropathy [132].
- Dynamic ultrasonographic assessment of changes in the AP diameter and CSA is an effective diagnostic tool for identifying radial tunnel syndrome [121].
- Ultrasonography, computed tomography, and magnetic resonance imaging revealed the location of the ganglion in every patient with radial nerve palsy caused by a ganglion [124].
- The authors acknowledge that their study does not establish diagnostic accuracy or a reference standard for radial tunnel syndrome [49].
Treatment¶
Non-Operative Management¶
- Current best evidence for the conservative management of radial tunnel syndrome consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes [3].
- The effectiveness of conservative treatments for radial tunnel syndrome is unknown because, for most treatments, no studies are available [48].
- Prospective evaluation of a single corticosteroid injection demonstrated improvement in standardized outcomes measures of pain and function at one year in 75% of patients presenting with symptoms of radial tunnel syndrome [8].
- Nonsurgical management is first-line for radial tunnel syndrome [4].
- The two most common nerve entrapment disorders about the elbow, including radial tunnel, should be initially managed conservatively before considering surgical intervention [80].
Operative Management¶
- Surgical decompression remains a viable option for refractory cases of radial tunnel syndrome despite ongoing controversy regarding diagnosis and outcomes [4].
- There is a tendency that surgical decompression of the radial tunnel might be effective in patients with radial tunnel syndrome [48].
- The authors advocate for surgery in high radial nerve entrapment neuropathy cases resistant to conservative treatment, emphasizing the importance of dissecting the entire length of the fibrous tunnel [17].
- This study indicates that pain in patients with radial tunnel syndrome may be treated successfully by surgical decompression of the superficial branch of the radial nerve [104].
- The results of radial tunnel release have been sufficiently good thus far as to warrant some attention, with an overall significant improvement in 99 of 108 cases (91.7%) when combined with other series [19].
- Nineteen patients (20 extremities) felt satisfied and helped and believed they gained improved function because of surgical decompression of the radial tunnel [27].
- The authors believe that a high rate of morbidity is associated with both the disease and its treatment, suggesting that great caution has to be taken before performing radial tunnel release [26].
- The authors suggest that great caution be taken before performing radial tunnel release and strict adherence to the indications noted during the preoperative examination [50].
Evidence Limitations and Controversy¶
- There has been no randomized controlled trial that compares surgical with nonsurgical treatment or with a placebo for radial tunnel syndrome [20].
- Skeptics of radial tunnel syndrome point to the great variability of surgical results reported in the literature as one of the characteristics of placebo surgery [20].
- Although radial tunnel syndrome is classically described as a nerve compression and entrapment syndrome, there is dispute over its etiology [20].
Complications¶
- A high rate of morbidity is associated with both radial tunnel syndrome and its treatment [26].
- In a case of congenital compression of the radial nerve, the patient was followed for an additional 3 months without clinical improvement in radial nerve function [12].
- Nerve injury is an uncommon though troublesome complication of fractures or dislocations of the elbow [39].
Recovery¶
- A patient with congenital compression of the radial nerve was followed for an additional 3 months without clinical improvement in radial nerve function [12].
- In a patient with posterior interosseous-nerve syndrome secondary to rheumatoid synovitis where the duration of entrapment was more than two years, a tendon transfer was used as treatment [139].
- Isolated posterior interosseous nerve neurectomy has shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up [123].
Key Evidence¶
- [L5] Radial tunnel syndrome is relatively uncommon but is an important cause of lateral forearm pain, with clinical examination being a crucial part of the diagnosis. [1] (10.1197/j.jht.2006.02.005)
- [L4] The duration of symptoms averaged 2.3 years before a definitive diagnosis of radial tunnel syndrome was made. [2] (10.1016/s0363-5023(83)80201-9)
- [L5] Current best evidence for the conservative management of radial tunnel syndrome (RTS) consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes. [3] (10.1197/j.jht.2006.02.020)
- [L4] The article reviews the anatomy, diagnosis, and treatment of radial tunnel syndrome, noting that while nonsurgical management is first-line, surgical decompression remains a viable option for refractory cases despite ongoing controversy regarding diagnosis and outcomes. [4] (10.5435/jaaos-d-23-00314)
- [L4] The diagnosis of radial tunnel syndrome remains clinical, and adherence to a defined protocol is useful in diagnosing this condition. [5] (10.1016/s0266-7681(98)80015-6)
- [L5] A case of bilateral radial tunnel syndrome with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression. [6] (10.1177/15589447211029045)
- [L5] The issue surrounding radial tunnel syndrome traditionally has been properly identifying it clinically. [7] (10.1097/01.bth.0000231580.32406.71)
- [L4] Prospective evaluation of corticosteroid injection demonstrated improvement in standardized outcomes measures of pain and function at one year in 75% of patients presenting with symptoms of radial tunnel syndrome. [8] (10.1016/j.jhsa.2017.06.095)
- [Paper] Compression of the radial nerve at the elbow is of moderate frequency compared to the ulnar tunnel syndrome. [9] (10.1016/j.main.2004.10.006)
- [L4] The Rule-of-Nine test effectively specifies the site of tenderness for the diagnosis of radial tunnel syndrome. [11] (10.1177/230949900401200115)
- [L5] The patient was followed for an additional 3 months, without clinical improvement in radial nerve function. [12] (10.1016/s0363-5023(89)80099-1)
- [L4] A diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment. [13] (10.1016/s0266-7681(05)80152-4)
- [L5] Radial tunnel syndrome is an illness construct based on a speculative pathophysiology with no verifiable pathophysiology or accepted reference standard for diagnosis. [14] (10.1016/j.jhsa.2010.03.020)
- [L4] A differential latency of ≥0.30 ms was considered indicative of radial tunnel syndrome. [16] (10.1016/s0363-5023(98)80163-9)
- [Case_report] The authors advocate for surgery in high radial nerve entrapment neuropathy cases resistant to conservative treatment, emphasizing the importance of dissecting the entire length of the fibrous tunnel. [17] (10.1016/j.jse.2025.02.060)
- [L4] The results of radial tunnel release have been sufficiently good thus far as to warrant some attention, with an overall significant improvement in 99 of 108 cases (91.7%) when combined with other series. [19] (10.1016/s0363-5023(79)80105-7)
- [L5] [20] (10.1016/j.jhsa.2009.10.016)
- [L5] Radial tunnel syndrome is a pain syndrome caused by compression of the posterior interosseous nerve at the proximal forearm. [22] (10.1016/j.ocl.2012.07.022)
- [L5] It is important to understand the anatomic course and distribution of the radial nerve in order to make an accurate diagnosis. [24] (10.1007/s11420-011-9238-8)
- [L5] The authors believe that a high rate of morbidity is associated with both the disease and its treatment, suggesting that great caution has to be taken before performing radial tunnel release. [26] (10.1097/00130911-200212000-00010)
- [L4] Nineteen patients (20 extremities), however, felt satisfied and helped and believed they gained improved function because of surgical decompression of the radial tunnel. [27] (10.1016/s0363-5023(97)80086-x)
- [L5] Radial tunnel syndrome (RTS) and posterior interosseous nerve (PIN) compression are distinct entities with different clinical presentations but share identical potential sites of nerve interference; the author proposes unifying them as mild (RTS) and severe (PIN compression) forms of one disease to simplify nomenclature. [29] (10.1177/1753193420953990)
- [L4] Muscle denervation edema or atrophy along the distribution of the posterior interosseous nerve is the most common MR finding in radial tunnel syndrome. [32] (10.1148/radiol.2401050028)
- [L4] Nerve injury is an uncommon though troublesome complication of fractures or dislocations of the elbow. [39] (10.1016/s0020-1383(79)80015-7)
- [L4] [48] (10.1016/j.jhsa.2007.10.001)
- [Paper] The authors acknowledge that their study does not establish diagnostic accuracy or a reference standard for radial tunnel syndrome. [49] (10.1177/17531934261463150)
- [L4] The authors suggest that great caution be taken before performing radial tunnel release and strict adherence to the indications noted during the preoperative examination. [50] (10.1053/jhsu.1999.0566)
- [L5] A symptomatic double-level entrapment of the posterior interosseous branch of the radial nerve is described. [51] (10.1016/s0363-5023(83)80202-0)
- [L5] The authors advocate for consistent use of the terminology distinguishing the deep branch of the radial nerve (DBRN) and the posterior interosseous nerve (PIN), and recommend viewing radial tunnel syndrome and posterior interosseous nerve syndrome as a single condition presenting along a spectrum of nerve entrapment. [52] (10.1177/17531934241254706)
- [L2] [81] (10.1016/j.jhsa.2024.09.023)
- [L5] [88] (10.1016/j.jisako.2024.03.001)
- [L4] This study indicates that pain in patients with radial tunnel syndrome may be treated successfully by surgical decompression of the superficial branch of the radial nerve. [104] (10.1177/1753193408099832)
- [L5] Supination increases the linear distance between the PIN and radial head and should be considered to increase the safe working volume whenever intra-articular procedures are performed on the anterolateral aspect of the elbow. [107] (10.1016/j.jse.2018.08.019)
- [L4] Dynamic ultrasonographic assessment of changes in the AP diameter and CSA is an effective diagnostic tool for identifying radial tunnel syndrome. [121] (10.1177/17531934261443138)
- [L4] Isolated PINN have shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up. [123] (10.1177/1558944717692093)
- [L4] Ultrasonography, computed tomography, and magnetic resonance imaging revealed the location of the ganglion in every patient. [124] (10.1016/s0363-5023(10)80102-9)
- [L4] Neuroimaging should be considered as a complementary diagnostic method in PINS. [132] (10.1212/wnl.0000000000003287)
- [L4] In the third patient, in whom the duration of entrapment was more than two years, a tendon transfer was used as treatment. [139] (10.2106/00004623-197355040-00009)
References¶
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