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Background and Purpose. Lateral elbow pain has several causes, which
can make diagnosis difficult. The purpose of this case report is to
describe the examination of and the intervention for a patient with
chronic lateral elbow pain who had signs of nerve entrapment. Case
Description. The patient was a 43-year-old woman who had right lateral
elbow pain for about 4 months, which she attributed to extensive
keyboard work on a computer. She had a reduction in joint passive
range of motion during neural tension testing, an examination
procedure to detect nerve entrapment. This sign, in combination with
other findings, suggested that the patient had a mild entrapment of
the deep radial nerve (radial tunnel syndrome). The patient was
treated 14 times over a 10-week period with neural mobilization
techniques, which are designed to free nerves for movement; ultrasound; strengthening exercises; and stretching. Outcomes. The patient
had minimal symptoms at discharge, was pain-free, and had resumed
all activities at a 4-month follow-up visit. Discussion. Neural tension
testing may be a useful examination procedure and mobilization may
be useful for intervention for patients who have lateral elbow pain.
[Ekstrom RA, Holden R. Examination of and intervention for a patient
with chronic lateral elbow pain with signs of nerve entrapment. Phys
Ther. 2002;82:10771086.]
Key Words: Lateral elbow pain, Nerve entrapment, Neural tension testing, Radial tunnel syndrome.
1077
Entrapment of the deep radial nerve has been demonstrated during surgical release procedures that have
successfully relieved pain and other signs associated with
RTS.9,10,13,15,16 Common sites of entrapment are the
tendinous margin at the origin of the ECRB muscle,9,10
the arcade of Frohse of the supinator muscle,9,10,13,15 and
the distal border of the supinator muscle.17 Prasartritha
et al11 demonstrated a well-developed fibrous arch at the
arcade of Frohse in 34 of 60 cadaver specimens and a
thick fibrous edge at the distal border of the supinator
muscle in 39 of the specimens. It has been implied that
the fibrous tissue is a reason for entrapment of the
nerve.13 In patients, the exact cause of deep radial nerve
compression can only be determined at the time of a
surgical procedure.
Symptoms of RTS may masquerade as lateral epicondylitis. The examination for RTS should include a thorough history. The symptoms may include deep, aching,
diffusely localized pain around the lateral side of the
elbow and dorsal side of the forearm that sometimes
radiates to the hand.10,13,16,18 The pain is initiated and
intensified by repetitive movements incorporating forearm pronation.10 It has been postulated that repetitive
pronation or supination movements may cause fibrosis
of the arcade of Frohse, leading to a greater chance of
entrapment.13
We believe that the examination also should include
palpation for abnormal tenderness over the radial tunnel (Fig. 2). The forearm is placed in neutral pronation/
supination and palpated in a line anterior to the radiohumeral joint to the midpoint between the radius and
ulna on the posterior aspect of the forearm over a
relaxed ECRB muscle. The tunnel is about as long as the
width of 4 palpating fingertips (5 6 cm), as pictured in
Figure 2.10 Greater tenderness should be expected over
RA Ekstrom, PT, DSc, OCS, is Assistant Professor, Department of Physical Therapy, University of South Dakota, 414 E Clark St, Vermillion, SD
57069 (USA) (rekstrom@usd.edu). Address all correspondence to Dr Ekstrom.
K Holden, PT, MSPT, is Physical Therapist, Department of Physical Therapy, Sioux Valley Vermillion Hospital, Vermillion, SD.
Both authors provided writing and data collection and analysis. Dr Ekstrom provided idea/project design and project management. Ms Holden
provided subjects, facilities/equipment, and consultation (including review of manuscript before submission).
This article was submitted September 7, 2001, and was accepted May 12, 2002.
Figure 2.
Palpation of the radial tunnel.
Case Description
Patient
The patient was a 43-year-old woman. She was employed
as a secretary and performed a variety of tasks, including
extensive keyboard work at a computer.
Examination
The patient started experiencing right lateral elbow pain
about 4 months before being referred for physical
therapy. She could not identify an injury, but attributed
her problem to the many hours of computer keyboard
work each day at her job. Her elbow pain varied from day
to day, depending on her activities and use of the right
upper extremity. In addition to using a keyboard, she
found that other gripping or repetitive activities, such as
using a scissors or stirring while baking, aggravated her
symptoms (caused increased lateral elbow pain).
Using a visual analog scale (VAS), where 0 was no pain
and 10 was the most severe pain imaginable, her pain
level varied from 1.0 to 6.0, depending on her activity
level. The VAS has been shown to have test-retest reliability of .97 using a Pearson product moment correlation when comparing individuals or groups of patients
examined.29 We did not assess the reliability of our own
measurements.
The pain initially started as an ache in her elbow and
gradually increased in intensity over time. The patient
pointed to an area corresponding to the radial tunnel as
the location of her pain. She said that she occasionally
felt a burning type of pain over the lateral epicondyle
area of the right elbow.
The cervical spine was examined first with the patient in
a sitting position. Cervical range of motion (ROM) was
within normal limits for her age.30 Cervical compression
and distraction tests were negative. Cervical compression
was applied by placing downward pressure over the
Figure 3.
Median nerve test with shoulder girdle depression, shoulder abduction,
shoulder lateral (external) rotation, and wrist and finger extension with
the forearm supinated and then elbow extension.
The passive joint ROM during nerve testing was measured with a universal goniometer. Goniometric measurements of upper-extremity joint movements have
been found to have excellent intratester and intertester
reliability.34,35 Rothstein et al34 measured elbow flexion
and extension of patients with a goniometer and found
intratester reliability of r .91 to .99 and intertester
reliability of r .88 to .97. Using analysis of variance for
repeated measures, Boone et al35 concluded that when
the same tester measures the same ROM of an upperextremity joint, the measurements will vary less than 3 to
4 degrees. When different testers measure the same
upper-extremity motion, the measurements will vary less
than 5 degrees. Therefore, we were confident that our
goniometric measurements of upper-extremity joint
motions were reliable and accurate.
The passive ROM measurements for the left and right
upper-extremity joints during the nerve tests are shown
in Table 1 for the median nerve and in Table 2 for the
radial nerve. Based on work by Coppieters et al,36 passive
ROM in both extremities was less than what would be
considered normal, and the ROM of the right upper
extremity was much more limited than that of the left
upper extremity. In a normal tension test, we could
expect a limitation of a few degrees of ROM only in the
joint that is moved last in the sequence because it is the
last movement that places maximum stretch on the
nerve. With the median nerve test, Coppieters et al36
found an average limitation of 11 degrees of elbow
extension when the wrist was extended before the elbow.
The radial nerve test reproduced the pain in the right
lateral elbow area, whereas the median nerve test did not.
Figure 4.
Radial nerve test with shoulder girdle depression, forearm pronation,
elbow extension, wrist and finger flexion, and shoulder abduction.
Evaluation
The examination of the cervical spine and the radiohumeral joint did not reproduce pain in the right elbow.
When generating muscle force for testing and stretching, the patient reported pain that was similar to those of
patients who have either lateral epicondylitis or RTS.
The patient had pain that was often a burning sensation
over the lateral elbow area, which in our experience with
patients with nerve injuries is more indicative of a nerve
irritation than lateral epicondylitis. The patient had
signs of nerve entrapment in both upper extremities,
and the ROMs of the joints of the right upper extremity
were more limited than those in the left upper extremity. The patient did not have much pain over the lateral
epicondyle during palpation, but she had acute pain
when the radial tunnel was palpated. Resistance to
middle finger extension or forearm supination caused
more pain over the radial tunnel than over the lateral
epicondyle.
Based on the results of manual muscle testing, the
patient had weakness in the wrist, thumb, and finger
extensors, and she also had decreased grip force. It was
not possible to determine whether this weakness was due
to pain or due to the partial denervation of these
muscles that can occur with entrapment neuropathies.
Even though the results of force testing may not have
contributed to diagnosis, we believe it is very important
to examine for force deficits.
We concluded that the patients primary problem was an
entrapment of the deep radial nerve. Using the Guide to
Physical Therapist Practice,37 the patients problem could
be classified under Preferred Practice Pattern 4E
(Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation) or 5F (Impaired Peripheral Nerve
Table 1.
Passive Joint Range of Motion Measurements Recorded During Testing for Entrapment of the Median Nerve
Initial
7 Days (4 Visits)
14 Days (6 Visits)
21 Days (8 Visits)
Left
Right
Left
Right
Left
Right
Left
Right
3.5
60
49
75
32
2.5
40
12
40
64
NTa
NT
NT
NT
NT
3.0
67
20
75
35
4.0
90
90
75
10
4.0
72
60
75
40
4.0
90
90
75
10
4.0
90
90
75
20
NTnot tested.
Table 2.
Passive Joint Range of Motion Measurements Recorded During Testing for Entrapment of the Radial Nerve
Initial
7 Days (4 Visits)
14 Days (6 Visits)
21 Days (8 Visits)
Left
Right
Left
Right
Left
Right
Left
Right
3.5
85
0
65
65
2.5
85
20
0
47
NTa
NT
NT
NT
NT
3.0
85
12
0
50
NT
NT
NT
NT
NT
4.0
85
10
10
50
4.0
85
0
65
65
4.0
85
0
65
65
NTnot tested.
Table 3.
Initial
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Follow-up (4 mo)
a
Least Pain
Most Pain
1.0
1.0
1.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
6.0
6.0
4.0
4.0
2.0
2.8
2.5
2.8
2.0
1.8
2.1
0.0
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