b'CODING Update ComplianceLEGAL NUTRITIONUpdateANJC NewsANJC Leadership ANJC News! NUTRITION LEGAL EASEANJC Scholarship REHAB Update Executive Directors Update LEGAL Q&A CHIRO AssistINSURANCE Update INSURANCE Update Legislative UpdateTennis Elbow TECHNIQUE Updateor Radial TunnelSyndrome? By Dr. Tim BertelsmanMedicareQ&AMedicare Update TennisElboworRadialTunnelSyndrome?Chiropractors are well suited to recognize and manageOUR HEALTHByDr.TimBertelsman Clinical Presentationlateral epicondylitis. In fact, we often jump to the diagnosis Presenting symptoms depend on whether irritation affects within seconds of hearing the patients history. Unfortunately,the sensory branch, motor branch or both. Compression or Chiropractors are well suited to recognize and manage lateral epicondyli6s. In fact, wenot all pain near the lateral epicondyle is simply from tennisirritation of the superficial sensory branch results in pain, o;en jump to the diagnosis within seconds of hearing the pa6ents history. Unfortunately,elbow. Radial tunnel syndrome can mimic or even coexistparesthesia or diminished sensitivity along the dorsal aspect not all pain near the lateral epicondyle is simply from tennis elbow.Radial tunnelwith lateral epicondylitis, and recognizing this presentationof the forearm sometimes radiating to the hand, including syndrome can mimic or even coexist with lateral epicondyli6s, and recognizing thisparesthesia or diminished sensi6vity along the dorsal aspect of the forearm some6meswill afford better clinical outcomes. the first web space and back of the thumb and index finger.presenta6on will aord beDer clinical outcomes. (11)radia6ng to the hand, including the rst web space and back of the thumb and indexThe radial tunnel is defined as the space surrounding the These symptoms are often described as deep, aching nger. (11) These symptoms are o;en described as deep, aching and diuse, some6mesradial nerve as it traverses the posterior forearm from theand diffuse, sometimes mimicking lateral epicondylitis. (12)The radial tunnel is dened as the space surrounding the radial nerve as it traverses the(1) mimicking lateral epicondyli6s. (12) Compression of the posterior interosseous nerveradiocapitellar joint thru the supinator muscle.RadialCompression of the posterior interosseous nerve (motor posterior forearm from the radiocapitellar joint thru the supinator muscle. (1) Radial(motor branch) manifests as weakness of metacarpophalangeal joint extension andtunnel syndrome describes symptoms generated frombranch) manifests as weakness of metacarpophalangeal joint tunnel syndrome describes symptoms generated from irrita6on or compression of the (2)irritation or compression of the radial nerve within this extension and thumb extension, also called finger drop. thumb extension, also called nger drop. (2)Wrist extension is generally not aectedradial nerve within this 2 tunnel. Wrist extension is generally not affected as noticeably 2 tunnel.as no6ceably because of cross-innerva6on.because of cross-innervation.There are multiple potential sites of compression in the radial There are mul6ple poten6al sites of compression in the radial tunnel that may aect thesensory branch of the radial nerve, the motor branchalso called the posteriortunnel that may affect the sensory branch of the radial nerve, interosseous nerve, or both. (2) Compression of the supercial sensory branch results inthe motor branchalso called the posterior interosseous purely sensory symptoms, while compression of the posterior interosseous nervenerve, or both. (2)Compression of the superficial sensory produces motor weakness of the nger, hand and wrist extensors.branch results in purely sensory symptoms, while compres- sion of the posterior interosseous nerve produces motor weakness of the finger, hand and wrist extensors. Deeply palpa6ng and rolling your ngers over the radial nerve four nger breaths distal toDeeply palpating and rolling your fingers over the radial the lateral epicondyle should provoke symptoms (radial tunnel compression test). (13)nerve four finger breadths distal to the lateral epicondyle Symptoms are generally intensied by resisted wrist extension, supina6on and prona6on.should provoke symptoms (radial tunnel compression test).(13)Symptoms are generally intensified by resisted wristResisted muscle tes6ng can help localize the site of compression. (14)Reproduc6on ofextension, supination and pronation. Resisted muscle testing symptoms upon resisted supina6on, when the arm and wrist are in extension, suggestscan help localize the site of compression. (14)Reproduction compression at the arcade of Frohse (Resisted supina6on test). Reproduc6on ofof symptoms upon resisted supination, when the arm and symptoms during resisted extension of the middle nger suggests compression of thewrist are in extension, suggests compression at the arcade of posterior interosseous nerve beneath the extensor carpi radialis brevis (resisted longFrohse (Resisted supination test). Reproduction of symptoms nger extension, aka, middle nger sign). (13) Tinel sign or reproduc6on of symptoms byduring resisted extension of the middle finger suggests The most common site of compression within the radialpercussion of the radial nerve is infrequently present.compression of the posterior interosseous nerve beneath the tunnel is beneath a thickened, fibrous proximal edge of the extensor carpi radialis brevis (resisted long finger extension, The most common site of compression within the radial tunnel is beneath a thickened,aka, middle finger sign). (13)Tinel sign or reproduction of supinator muscle, also called the Arcade of Frohse. ThisSeventy percent of pa6ents with lateral elbow pain demonstrate symptoms or posi6vebrous proximal edge of the supinator muscle, also called the Arcade of Frohse. Thisthickening is thought to be developmental as a result ofsymptoms by percussion of the radial nerve is infrequently clinical ndings in the cervical or upper thoracic regions.Posi6ve ndings include limitedthickening is thought to be developmental as a result of repe66ve strain and is present inrepetitive strain and is present in 30-80% of the population (3,4) present.range of mo6on in exion and extension and posi6ve provoca6on tes6ng. (15)30-80% of the popula6on. (3,4) Compression of the posterior interosseous nerve beneathCompression of the posterior interosseous nerve beneath Neurodynamic testing/ tensioning of the radial nerve may provoke symptoms. Palpa6onSeventy percent of patients with lateral elbow pain the Arcade of Frohse is some6mes referred to as supinator syndrome and accounts forthe Arcade of Frohse is sometimes referred to as supinatordemonstrate symptoms or positive clinical findings in the elicits tenderness over the radial nerve and some6mes over the lateral epicondyle makingalmost 70% of all radial tunnel presenta6ons. (3) Other sites of entrapment include thesyndrome and accounts for almost 70% of all radial tunnelcervical or upper thoracic regions. Positive findings include dieren6a6on of the two condi6ons challenging.The pain of radial tunnel syndromedistal border of the supinator muscle and beneath the origin of the extensor carpi radialispresentations. (3)Other sites of entrapment include the distallimited range of motion in flexion and extension and positive brevis muscle. (5,6,29) should be more acute distally. (16) Nocturnal pain is more common in radial tunnelborder of the supinator muscle and beneath the origin of theprovocation testing. (15)Neurodynamic testing/tensioning of (5,6,29) pa6ents than those with lateral epicondyli6s. (17)extensor carpi radialis brevis muscle. the radial nerve may provoke symptoms. Palpation elicits ClinicalPresentaonRadial tunnel syndrome occurs less frequently than its more common upper extremity18 I Summer 2020 www.anjc.infoPresen6ng symptoms depend on whether irrita6on aects the sensory branch, motorcousins: carpal tunnel syndrome and cubital tunnel syndrome. (7,8) Radial tunnelbranch or both. Compression or irrita6on of the supercial sensory branch results in pain,syndrome frequently accompanies these and other co-morbidi6es including: pronatorparesthesia or diminished sensi6vity along the dorsal aspect of the forearm some6messyndrome, Guyons syndrome, medial epicondyli6s, de Quervains tenosynovi6s, triggernger and lateral epicondyli6s. (9) Research suggests that up to 10% of pa6ents withlateral epicondyli6s have co-existent radial tunnel syndrome. (10) Radial tunnel syndromeis thought to result from overuse, especially forceful handgrip work, excessive wristextension, prona6on, supina6on or vibra6on. (27,28) Diagnoscs&Dierenal Radiographs are seldom indicated unless needed to rule out osseous pathology. Ultrasound and MRI may be used to detect space occupying lesions and to localize thespecic site of nerve involvement. (18,19) EMG/NCS studies are typically nega6ve butmay highlight muscle innerva6on decits in cases with signicant posterior interosseousnerve involvement. (20,21) Other dieren6al diagnos6c considera6ons for radial tunnel syndrome include:Wartenbergs syndrome/cheiralgia paresthe6ca (aka handcu neuropathy from'