䢇

Case Report

Examination of and Intervention for

a Patient With Chronic Lateral Elbow
Pain With Signs of Nerve Entrapment
Background and Purpose. Lateral elbow pain has several causes, which
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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; ultra-
sound; 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;82:1077–1086.]

Key Words: Lateral elbow pain, Nerve entrapment, Neural tension testing, Radial tunnel syndrome.

Richard A Ekstrom, Kari Holden

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Physical Therapy . Volume 82 . Number 11 . November 2002 1077


L
ateral elbow pain has been attributed to several
causes.1–7 It is most often associated with lateral
epicondylitis, which is an overuse injury to the
common extensor tendon, with the extensor
carpi radialis brevis (ECRB) tendon being the tendon
most frequently affected.1 The degree of injury may
range from minor disruption of collagen fibers to
partial- or full-thickness tears of the ECRB tendon at its
attachment to the lateral epicondyle.1 Microscopic stud-
ies have demonstrated that the condition is a degenera-
tive process of the tendon with little or no evidence of
inflammation; therefore, lateral epicondylitis should be
classified as a tendinosis rather than a tendinitis.1–3
Other problems that may cause lateral elbow pain are
radiohumeral joint pathology and dysfunction of the
cervical spine at C5– 6 or C6 –7, which may cause referral
of pain to the lateral elbow area.1,4 –7 The radial wrist
extensors are primarily of the C6 myotome, and the
lateral epicondyle is considered to be in the C7
sclerotome.8
Another cause of lateral elbow pain is radial tunnel
syndrome (RTS) associated with entrapment of the deep
radial nerve.9,10 The radial tunnel begins where the
radial nerve runs in a furrow between the brachioradialis
and brachialis muscles in the distal part of the arm.11,12
About 1.3 cm proximal to the radiohumeral joint, the
radial nerve divides into a superficial branch and a deep
branch (Fig. 1). The deep radial nerve continues into
the radial tunnel and in most cases passes through a
fascial extension from the origin of the ECRB muscle,
innervates it, and gives off a small recurrent branch that
travels laterally to the lateral epicondyle.11,13 The nerve
then courses under the arcade of Frohse, which is a
semicircular arch at the proximal edge of the supinator
muscle about 2.3 cm distal to the radiohumeral joint.11
The nerve passes through the substance of the supinator
muscle, innervates it, and exits the supinator muscle
about 6.4 cm distal to the radiohumeral joint, where the
radial tunnel terminates.9 As the deep radial nerve exits
the supinator muscle, it is called the posterior interosse-
ous nerve (PIN).12,14 The PIN divides into terminal
branches that innervate the extensor digitorum, exten-
sor digiti minimi, extensor carpi ulnaris, extensor polli-
cis longus and brevis, extensor indicis, and the abductor
pollicis longus muscles.14
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.
1078 . Ekstrom and Holden
Lateral elbow pain can be difficult to
diagnose because of the different
pathologies or combinations of
pathologies that can cause it.
Entrapment of the deep radial nerve has been demon-
strated 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 epicondy-
litis. The examination for RTS should include a thor-
ough 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 fore-
arm 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 tun-
nel (Fig. 2). The forearm is placed in neutral pronation/
supination and palpated in a line anterior to the radio-
humeral 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
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the radial tunnel than at the lateral
epicondyle, indicating an RTS.10,13
Compression of the deep radial nerve is
another part of the examination. The
deep radial nerve can be compressed
by stretching the supinator muscle by
pronating the forearm to end-range
with the elbow extended.17 Pronation
also is believed to tighten the fascial
origin of the ECRB muscle over the
nerve.9 Resistance to supination with
the supinator and ECRB muscles in the
stretched position will cause further
compression of the nerve.10

Resistance applied to extension of the

middle finger with the elbow extended
and the wrist in neutral extension9,10,19
can cause increased pain with either
lateral epicondylitis or RTS. We believe
that the key is to determine the loca-
tion of the increased pain during the
test. Pain over the lateral epicondyle
would be more indicative of lateral
epicondylitis, and pain over the radial
tunnel would indicate a possible RTS.
An explanation for increased pain with
Figure 1. RTS is that resistance to extension of
Radial tunnel. On the left, the deep radial nerve is seen passing under the fascial extension of the middle finger indirectly causes the
the origin of the extensor carpi radialis brevis muscle, and, on the right, it continues through the
ECRB muscle to contract, tightening its
arcade of Frohse and the substance of the supinator muscle. Reprinted with permission from
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, fascial origin, which overlays the deep
Md: Lippincott Williams & Wilkins; 1983:485. radial nerve.9,10 Similar resistance to
extension of the other fingers may
cause pain in RTS, but is not as
severe.10 During muscle force testing of the muscles
innervated by the PIN, the finger and thumb extensors
may be found to be weak.20 Radial nerve blocks some-
times are used by physicians in diagnosing RTS.21 How-
ever, a nerve block also might reduce the pain with
lateral epicondylitis, making it a rather nondiscriminat-
ing test. We recommend that the examination also include
what has been called “neural tension testing,”22–24 a proce-
dure designed to detect nerve entrapment.

Research has demonstrated that nerves normally move

in relation to their surrounding connective tissues.25,26
Entrapment of a nerve could restrict its movement,
placing tension on the nerve during some motions of the
Figure 2. upper extremity. The abnormal tension produced in the
Palpation of the radial tunnel. nerve has been called “adverse mechanical tension.”22–24
In addition, entrapment may cause ischemia, inflamma-
tion, and pain, or even axonal degeneration in the
nerve.24 Injured or inflamed peripheral nerves usually
have increased sensitivity to mechanical loading.27,28
Nerve tension testing, which places mechanical tension

Physical Therapy . Volume 82 . Number 11 . November 2002 Ekstrom and Holden . 1079
on a nerve, would be expected to increase pain from the
nerve.
Butler24 described nerve tension testing positions and
mobilization techniques for the nerves of the upper
extremity. Butler and others believe that the mobility of
a nerve that has restricted longitudinal movement often
can be restored using what they call “neural mobilization
techniques,”23,24 which are techniques designed to free
nerves for movement. We could find no research evi-
dence that a nerve can be mobilized once its motion is
restricted. 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
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 reli-
ability of .97 using a Pearson product moment correla-
tion 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
1080 . Ekstrom and Holden
crown of the head for 5 seconds with the neck rotated,
side bent, and extended to each side. Distraction of the
neck was applied by placing one hand under the occiput
and one hand under the chin and then lifting upward
for 5 seconds. None of the movements of the cervical
spine reproduced the elbow pain.
The passive ROM of her left and right shoulders, elbows,
wrists, and fingers was examined. Her ROM was within
normal limits,31 and she did not have pain in any of the
joints during passive movements. Compression and dis-
traction of the radiohumeral joint also did not cause
pain. Passive stretching of the extensor forearm muscu-
lature with the wrist and fingers flexed and elbow
extended caused moderate, tolerable pain, but no limi-
tation of the ROM.
Isometric contraction of the wrist extensor muscles and
resistance to middle finger extension with the elbow
extended caused pain in the area of the radial tunnel, as
did resisted forearm supination. Manual muscle testing
of the right wrist, finger, and thumb extensors revealed
force that was rated as 4/5. The force of the same muscle
groups on the left side was rated as 5/5. Grip force
(averaged for 3 contractions), as measured with a hand
dynamometer ( Jamar*) with the fingers flexed to mid-
range and with the elbow flexed to 90 degrees, was 28 kg
on the left with no pain and 14 kg on the right, which
produced increased but tolerable pain in the lateral
aspect of her elbow and proximal forearm. Peolsson et
al32 evaluated intrarater and interrater reliability when
determining grip force with a hand dynamometer and
obtained intraclass correlation coefficients ranging from
.85 to .98.
The patient had more pain when the radial tunnel was
palpated than when the right lateral epicondyle was
palpated. There was mild discomfort with palpation of
the lateral epicondyle, but acute pain with palpation of
the radial tunnel. She also had some tenderness when
the muscle bellies of the extensor carpi radialis longus
and extensor carpi radialis brevis muscles were palpated.
Neural tension testing was performed on both upper
extremities for comparison, using tests similar to those
proposed for the median and radial nerves.24 In the past,
the validity of neural tension testing has been based on
observation of how the nerves may be stretched with
movements and their anatomical positions in relation to
joints, rather than on data on the mechanical forces
actually produced in the nerves during different move-
ments or on data based on patient outcomes.23 Recently,
Kleinrensink et al33 used buckle force transducers to
assess the tensile forces in the nerves of cadavers during
* Sammons Preston, 4 Sammons Ct, Bolingbrook, IL 60440.
Physical Therapy . Volume 82 . Number 11 . November 2002

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.
nerve tension testing. They concluded that the median
nerve tension test was both sensitive and specific because
it produced a large amount of tension in the median
nerve with minimal tension produced in either the ulnar
nerve or the radial nerve. Based on the sensitivity and
specificity of the median nerve test, Kleinrensink and
colleagues concluded that the test is a valid test for
producing tension on the median nerve. They, however,
did not find the radial nerve test to be specific or
sensitive. Even though the radial nerve test produced the
greatest amount of tension in the radial nerve, the
tension was about 31% less in the radial nerve than in
the median nerve. When adding contralateral rotation
and side bending to the cervical spine, the tension in the
radial nerve was increased to slightly more than in the
median nerve. Because of the procedures used in the
study, we do not know if the tension produced would
cause pain in a patient.
The median nerve test was performed using 5 different
movements in sequence (Fig. 3). The movements were:
shoulder girdle depression with the elbow flexed to 90
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degrees, shoulder abduction with the elbow flexed to 90
degrees, shoulder lateral (external) rotation, wrist and
finger extension with the forearm supinated, and elbow
extension. Each movement was taken to a point of
perceived uncomfortable tension, according to patient
feedback, and then released just to the point where the
uncomfortable tension disappeared. At that point, pas-
sive joint ROM was recorded.
The radial nerve test also was performed using 5 differ-
ent movements in sequence (Fig. 4). Even though the
test is not specific to the radial nerve, it still produces the
greatest tension in the radial nerve than any other test
according to Kleinrensink et al.33 The first movement
was shoulder girdle depression with the elbow flexed to
90 degrees, followed by forearm pronation, elbow exten-
sion, wrist and finger flexion, and shoulder abduction.
Cervical side bending to the opposite side was not
included for either the median or radial nerve tests
because there was a large ROM loss and symptom
reproduction in this patient without it.
The passive joint ROM during nerve testing was mea-
sured with a universal goniometer. Goniometric mea-
surements 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 upper-
extremity 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.
Ekstrom and Holden . 1081

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 radio-
humeral joint did not reproduce pain in the right elbow.
When generating muscle force for testing and stretch-
ing, 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 extrem-
ity. 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 patient’s primary problem was an
entrapment of the deep radial nerve. Using the Guide to
Physical Therapist Practice,37 the patient’s problem could
be classified under Preferred Practice Pattern 4E
(“Impaired Joint Mobility, Motor Function, Muscle Per-
formance, and Range of Motion Associated With Local-
ized Inflammation”) or 5F (“Impaired Peripheral Nerve
1082 . Ekstrom and Holden
Integrity and Muscle Performance Associated With
Peripheral Nerve Injury”).
Intervention and Outcomes
The patient continued normal work activities through-
out the intervention period. She avoided other activities
that tended to aggravate her elbow.
The patient was treated with ultrasound (3 MHz at
0.5 W/cm2 for 8 minutes) over the radial tunnel for a
deep heating effect to improve soft tissue extensibility,
followed by “neural mobilization techniques” to reduce
the nerve entrapment for the first week of treatment (4
visits). These techniques were performed on both upper
extremities. Mobilizations were performed on the left
side only as a preventive measure with the notion that
reduced mobility of the nerves could cause problems in
the left upper extremity in the future. For mobilization
with presumably greater emphasis on the median nerve
(what sometimes is called “mobilization with a median
nerve bias”), the patient’s upper extremity was taken
through the sequence of movements used during test-
ing. This mobilization involved positioning, very similar
to that used for the median nerve test, that would place
the greatest amount of tension on the median nerve and
produce the greatest movement of the median nerve.
The mobilization was then performed by flexing and
extending the elbow.
For the mobilization with presumably a greater emphasis
on the radial nerve (what is sometimes called “mobiliza-
tion with a radial nerve bias”), the sequence was slightly
changed from the testing procedure so that mobilization
could be carried out with elbow flexion and extension.
This mobilization involved positioning, very similar to
that used for the radial nerve test, that would place the
greatest amount of tension on the radial nerve and
produce the greatest movement of the radial nerve. The
wrist and fingers were flexed prior to elbow extension
during the mobilization, whereas during the radial nerve
test, the elbow was extended prior to wrist and finger
flexion. In the early stages of mobilization of the right
side radial nerve, the fingers and wrist were not flexed
because elbow extension was limited without finger and
wrist flexion. As elbow extension improved, the fingers
and wrist were first flexed prior to the mobilization
procedure.
The mobilizations were performed gently, extending the
elbow for about 2 seconds just into the range where the
patient felt tension but no pain and then flexing the
elbow to the point where the patient felt no tension. Six
to 7 mobilizations were done emphasizing the median
nerve, followed by 6 to 7 mobilizations emphasizing the
radial nerve. The patient’s response dictated the degree
of elbow extension during mobilization. The patient did
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Table 1.
Passive Joint Range of Motion Measurements Recorded During Testing for Entrapment of the Median Nerve
Initial 7 Days (4 Visits)
Left Right Left
Shoulder depression (cm) 3.5 2.5 NTa
Shoulder abduction (°) 60 40 NT
Lateral (external) rotation (°) 49 12 NT
Wrist extension (°) 75 40 NT
Elbow extension (°) ⫺32 ⫺64 NT
a
NT⫽not tested.
not report pain prior to her perception of tension
during mobilization. Only with increasing tension did
she report any pain or discomfort. If pain or discomfort
or any signs, such as tingling in the hand, were pro-
duced, the range of elbow extension was reduced.
The patient was instructed to perform “neural mobiliza-
tion exercises” one time per day at home in a similar
manner to the technique used in the clinic. She was
taught how to perform the same sequence of extremity
positioning and then was taught how to use active elbow
extension as the mobilization movement. The patient
was seen 2 days after the first visit to again treat her and
review her home program to ensure she was progressing
well and not aggravating her condition with too aggres-
sive mobilizations. She was treated 2 more times over the
next 4 days to help facilitate the neural mobilization
process and ensure the home program was going well.
After the first week of physical therapy intervention, the
ROM in the right upper extremity during nerve testing
increased (Tabs. 1 and 2). The patient’s pain ratings on
the VAS, however, remained the same (Tab. 3). Her grip
force increased to 20 kg on the right. During palpation,
the patient indicated she had a small decrease in ten-
derness or pain over both the right lateral epicondyle
and radial tunnel. She initially had mild discomfort with
palpation of the right lateral epicondyle and acute pain
with palpation of the right radial tunnel. At that time,
the patient started a strengthening and stretching pro-
gram in addition to neural mobilization exercises. The
strengthening program consisted of resistive exercises
for the right wrist extensors with the elbow flexed to 90
degrees. The patient started with a 0.9-kg (2-lb) weight
and did 3 sets of 10 repetitions, with a 30-second stretch
of the wrist extensors after each set.38
At the time of the seventh physical therapist visit (2
weeks), the patient’s pain ratings on the VAS ranged
from 1.0 to 4.0, depending on the activities she per-
formed throughout the day. The day following the
seventh treatment, the patient was holding her dog’s
leash with her right hand when the dog suddenly bolted
after another dog, straining the patient’s right elbow.
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14 Days (6 Visits) 21 Days (8 Visits)
Right Left Right Left Right
3.0 4.0 4.0 4.0 4.0
67 90 72 90 90
20 90 60 90 90
75 75 75 75 75
⫺35 ⫺10 ⫺40 ⫺10 ⫺20
She had constant soreness and pain in the lateral aspect
of the right elbow for 3 days following the incident.
About 2 days later, the pain had returned to previous
levels.
As Tables 1 and 2 indicate, the patient’s passive ROM
continued to increase during testing that was designed
to stretch the nerves thought to be limited in movement,
in both her left and right upper extremities, during the
first 3 weeks of treatment (8 visits). The mobility was
nearly the same on the right and left sides. The right grip
force improved to 34 kg compared with the initial value
of 14 kg. The grip force of the left hand improved from
an initial value of 28 kg to 36 kg. The patient then could
perform her strengthening program for her right wrist
extensors with a 2.25-kg (5-lb) dumbbell. The patient
had no pain with self-stretching of the right wrist exten-
sors and minimal discomfort with a strong isometric
contraction of the wrist extensors. The patient was
pain-free unless she performed a considerable amount
of aggravating activities. Aggravating activities could still
increase pain levels to 4.0 on the VAS.
The patient continued with 6 more physical therapy
visits once a week, for a total of 14 visits over a 10-week
period. The goal of the last 6 weeks of intervention was
to get the patient to a point where all activities were
pain-free and to have the patient progress with her home
exercise program. At the time of the last visit, the passive
ROM of the upper extremities was maintained during
testing. The patient was able to perform the exercise
program with a 3.15-kg (7-lb) weight and the grip force
on the right had improved to 39 kg. She had minimal
tenderness or pain with palpation over the lateral epi-
condyle, the radial tunnel, and muscle bellies of the
extensor carpi radialis longus and brevis muscles. She
said she was pain free 70% to 80% of the time and only
had an aching type of pain when she performed activities
that would normally aggravate her elbow. Her employer
had provided her with a new ergonomically designed
workstation 2 weeks before the termination of physical
therapy, which she said helped to reduce stress on her
right upper extremity at work.
Ekstrom and Holden . 1083
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

Shoulder depression (cm) 3.5 2.5 NTa 3.0 NT 4.0 4.0 4.0
Forearm pronation (°) 85 85 NT 85 NT 85 85 85
Elbow extension (°) 0 ⫺20 NT ⫺12 NT ⫺10 0 0
Wrist flexion (°) 65 0 NT 0 NT 10 65 65
Shoulder abduction (°) 65 47 NT 50 NT 50 65 65
a
NT⫽not tested.

Table 3. Many of the patient’s signs and symptoms were similar to

Pain Rating on the Visual Analog Scalea those of patients with lateral epicondylitis, making it
difficult to distinguish between the 2 disorders. We
Least Pain Most Pain found a reduction in joint passive ROM during neural
Initial 1.0 6.0 tension testing that presumably required movement of
Week 1 1.0 6.0 the nerves. Yaxley and Jull39 evaluated “neural tension”
Week 2 1.0 4.0 in 20 patients with a diagnosis of tennis elbow and also
Week 3 0.0 4.0 found a tendency for reduced passive ROM during
Week 4 0.0 2.0
Week 5 0.0 2.8
testing in the upper extremity with the tennis elbow
Week 6 0.0 2.5 compared with the patients’ other upper extremity. The
Week 7 0.0 2.8 “neural tension test with a bias toward the radial nerve”
Week 8 0.0 2.0 reproduced the patients’ symptoms in 55% of the cases.
Week 9 0.0 1.8 It may be that some patients, including the patient in
Week 10 0.0 2.1
Follow-up (4 mo) 0.0 0.0
this case report, actually have a syndrome affecting both
the common extensor tendon of the forearm and the
a
0⫽“no pain,” 10⫽“the most severe pain imaginable.” deep radial nerve.

We believe that the “neural tension tests” and “neural

The patient was contacted 4 months after discharge
from physical therapy for follow-up on the status of her
right lateral elbow pain. She reported that she had
resumed all normal activity and was not having any pain
or other problems with her elbow.
Discussion
Lateral elbow pain can be difficult to diagnose because
of the different pathologies or combinations of pathol-
ogies that can cause it.1–7 The patient in this case report
had a variety of signs and symptoms that led us to
conclude that the primary problem was a mild entrap-
ment of the deep radial nerve that led to RTS. A more
severe entrapment of the deep radial nerve can lead to
paralysis of the muscles innervated by the PIN.13 In
retrospect, more precise manual muscle testing of the
muscles innervated by the PIN may have been of further
benefit in helping to make a definitive diagnosis. Some
of the muscles may have been able to be tested for force
without pain production and possible inhibition. Had we
found weakness in the muscles—such as the extensor
indicis or abductor pollicis longus—without pain pro-
duction, we believe it would have been a better indicator
that weakness was caused by neuropathy of the posterior
interosseous nerve rather than by pain.
mobilization techniques” performed were useful exami-
nation and intervention tools for this patient. Some
authors have proposed that, if a nerve’s gliding move-
ment is restricted in relation to surrounding tissues,
“adverse neural tension signs” can be produced in the
nerve during neural tension testing.22–24 The 2 most
prevalent signs are reduction in joint ROM and repro-
duction of symptoms.22 The most obvious sign demon-
strated by the patient was reduced joint passive ROM.
Symptoms were reproduced only with the test designed
to stretch the radial nerve. We believe that the radial
nerve test could have reproduced the symptoms with
either lateral epicondylitis or RTS. The radial nerve test
not only places tension on the nerve, but also places
tension on the muscles attaching to the lateral
epicondyle.
Studies25,26 have demonstrated that peripheral nerves
normally glide in relation to surrounding tissues. McLel-
lan and Swash25 inserted a needle electrode into the
trunk of the median nerve in the middle portion of the
arm in 15 subjects. Active and passive movements of wrist
extension and elbow flexion were performed. The move-
ments produced angulation of the needle electrode,
indicating that the tip of the electrode moved relative to

1084 . Ekstrom and Holden Physical Therapy . Volume 82 . Number 11 . November 2002

the site of entry through the skin. The movement of the
tip of the needle electrode was always abolished when
the electrode was withdrawn from the nerve by 1 mm,
indicating that adjacent soft tissues did not share in the
movement. McLellan and Swash demonstrated an aver-
age of 7.4 mm of excursion of the median nerve in an
inferior direction in the arm with extension of the wrist
and fingers and 4.3 mm of superior (upward) excursion
with elbow flexion. A deep inspiration of the lungs drew
the nerve toward the shoulder by as much as 8 mm.
Wilgis and Murphy,26 in a study using 15 fresh adult
cadavers, showed that the median and ulnar nerves
moved longitudinally at the elbow an average of 7.3 mm
and 9.8 mm, respectively, with full elbow flexion and
extension. The median nerve had 15.5 mm and the
ulnar nerve had 14.8 mm of longitudinal gliding at the
wrist with full arc wrist flexion and extension.26 The
superficial radial nerve moved longitudinally 5.8 mm
with movement from full radial deviation to full ulnar
deviation.26 The excursion of the nerves was measured
just proximal to each joint, relative to an adjacent fixed
joint, in which a Kirschner wire was driven into the
underlying bone.
The mechanical changes that occur in the peripheral
nerves and their surrounding tissues and how the passive
ROM of the peripheral joints is reduced when nerve
tension tests are applied have been described.33,36,40,41
Our patient had a reduction in the passive ROM in her
joints with both the median and radial nerve tension
tests. Kleinrensink et al33 demonstrated that nerve ten-
sion tests for the upper extremity may not be as discrim-
inatory for each nerve as we might have expected. They
found that the test for the median nerve is the most
specific, with considerably more tension produced in the
median nerve than in either the radial or ulnar nerves.
The radial nerve test produced more tension in the
median nerve than in the radial nerve, but it did place
more tension on the radial nerve than any other test.
When adding contralateral rotation and side bending to
the cervical spine, the tension in the radial nerve was
increased to slightly more than in the median nerve.
Elvey23 and Butler24 proposed that nerves with restricted
excursion can sometimes be mobilized. In the opinion
of Elvey,23 the mobilization should not go to the end of
range and should be of less duration than that used in
joint mobilization. We believe that testing procedures
and intervention techniques should never be of such
strength that symptoms are exacerbated. In this case
report, the mobilizations were performed gently and
only taken into the range of tension. If pain or discom-
fort was produced, the passive ROM of the mobilization
was reduced so that only tension was felt. The patient’s
joint ROM increased more quickly than we would expect
Physical Therapy . Volume 82 . Number 11 . November 2002
ўўўўўўўўўўўўўўўўўўўўўўўўўўў
if soft tissues, such as muscle or joint structures, were
being stretched.
It is not known whether outcomes for patients with
musculoskeletal problems would be better if decreased
joint passive ROM during nerve tension testing were
treated with “neural mobilization techniques,” which are
designed to free nerves for movement. It was interesting
that the patient’s left grip force improved even though
the only intervention for the left upper extremity was
mobilization that presumably freed up the nerve.
Whether the improvement was the result of the mobili-
zation, of motor learning from repeated testing, or of
some other cause could not be determined.
The intervention for the patient in this case report
included ultrasound during the first 4 visits, neural
mobilization techniques, progressive resistive exercises,
and stretching. Others have treated RTS with varying
results using ultrasound,19 anti-inflammatory medica-
tions,19 corticosteroid injections,42 and splinting.43 If a
patient does not respond to conservative treatment,
then surgical decompression of the deep radial nerve
may be indicated.13,17,19,44
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