Radial nerve elbow pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Patients who present to the office with lateral elbow pain most typically have lateral epicondylitis (tennis elbow).

However, when the patient's pain and dysfunction does not respond to therapy, the possibility of radial nerve entrapment, should be suspected.

In this situation, the radial nerve is squeezed where it passes through a tunnel near the elbow. The symptoms of radial nerve entrapment are very similar to the symptoms of tennis elbow.

The radial nerve originates from a nerve root in the neck. The nerve passes down the back of the upper arm. It then spirals and crosses the outside of the elbow before it travels down the forearm and hand.

Passing through the radial tunnel, the radial nerve runs below the supinator muscle. The supinator muscle is the muscle that helps with twisting the hand clockwise. This is the same motion used to use a screwdriver to tighten a screw.

After the radial nerve passes under the supinator muscle, it branches out and attaches to the muscles on the back of the forearm.

On the lateral part of the elbow, the radial nerve enters a tunnel formed by muscles and bone. This is called the radial tunnel. Radial nerve entrapment in the radial tunnel causes deep, dull lateral elbow pain with parathesias (numbness and tingling).

The primary clinical feature of RTS is lateral elbow pain. Repetitive, forceful pushing and pulling, bending of the wrist, gripping, and pinching can also stretch and irritate the nerve.

A second common physical finding is increased pain on resisted supination of the forearm (turning the forearm so that the palm faces towards the ceiling), which causes increased radial nerve impingement.

The major differential diagnostic points between radial nerve entrapment and lateral epicondylitis are: 1) the location with tenderness (in tennis elbow maximal tenderness is over the epicondyle and in RTS it is over the muscle mass); 2) passive elbow extension with wrist and finger flexion will increase epicondylitis pain while resisted supination will increase pain in RTS. It should be noted that both conditions may occur at the same time about five per cent of the time. Radial tunnel syndrome may also cause a more achy type of pain or fatigue in the muscles of the forearm.

The diagnosis of radial tunnel syndrome can be difficult.

An electromyogram (EMG) test may be done to see if the muscles of the forearm are working properly. If the test shows an issue with the muscles, it may be caused by a problem with the radial nerve. A nerve conduction velocity (NCV) test measures the speed of an electrical impulse as it travels along the radial nerve. It can show if the nerve is pinched. Unfortunately, these tests are not always accurate as far as diagnosing radial nerve entrapment.

Avoidance of activities that aggravate symptoms along with the use of a lightweight plastic arm splint while sleeping may help. Physical therapy also is useful. Therapists also use isometric exercises to improve forearm and hand strength without straining the tissues near the radial tunnel.

Sometimes symptoms of radial tunnel syndrome aren't relieved, even after conservative treatment. In these cases, surgery is an option. It is generally considered a last resort.

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