Radial Tunnel Syndrome (RTS) is a compression neuropathy affecting the radial nerve within the forearm, typically causing a deep, aching pain in the outside of the elbow and upper forearm. RTS is often mistaken for the more common condition of tennis elbow (lateral epicondylitis), which can lead to misdiagnosis and delayed recovery. Treatment follows a tiered approach, beginning with the least invasive methods and progressing only if symptoms persist, aiming to reduce pressure and inflammation on the nerve.
Initial Conservative Management
The initial phase of treatment focuses on reducing mechanical irritation and inflammation around the compressed nerve. This involves rest and modifying activities that stress the forearm. Patients must avoid repetitive forearm rotation, especially movements combining elbow extension with wrist flexion or forearm pronation, as these significantly increase tension on the radial nerve.
Splinting is a primary intervention used to maintain the wrist and forearm in a position of least strain. A wrist splint positioning the wrist in slight extension, or sometimes an elbow splint, helps immobilize the area and prevent irritating movements. This period of immobilization and activity restriction is typically recommended for four to six weeks, allowing the nerve a chance to recover from acute irritation.
Pharmacological support often includes over-the-counter Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen. These medications reduce local inflammation that may contribute to nerve compression. This initial conservative management is generally successful for the majority of patients and should be pursued diligently before escalating to more active or invasive treatments.
Targeted Physical Therapy and Rehabilitation
Once acute pain and inflammation are controlled, the focus shifts to restoring the nerve’s mobility and strengthening the surrounding musculature. This active phase is guided by a physical therapist using specific techniques. Nerve gliding exercises, often called neurodynamics, are introduced to encourage the radial nerve to slide smoothly through the forearm tunnel.
These glides involve gentle, sequential movements of the neck, shoulder, elbow, and wrist, designed to improve the nerve’s ability to move relative to the surrounding muscles. The goal is to reduce nerve adherence and tension without provoking pain. As the nerve begins to tolerate motion, the program expands to include targeted exercises for the forearm muscles.
Strengthening exercises focus on the wrist and finger extensors, which are often weakened or fatigued due to the nerve compression. This progressive resistance training helps to stabilize the elbow and wrist, improving the functional capacity of the arm. Manual therapy techniques, such as soft tissue mobilization, may also be used by the therapist to address any myofascial restrictions or muscle tightness contributing to the nerve irritation.
Advanced Non-Surgical Interventions
If symptoms persist despite a comprehensive trial of activity modification, splinting, and physical therapy—typically after three to six months—localized corticosteroid injections are the next common intervention. These aim to deliver a potent anti-inflammatory agent directly to the area of nerve compression. The injection is usually placed near the radial tunnel to reduce swelling and pressure on the nerve.
These injections are often performed under ultrasound guidance to ensure precise placement near the nerve, maximizing the therapeutic effect while minimizing risk to the surrounding structures. While they can provide significant, sometimes rapid, temporary relief, the frequency of corticosteroid injections is generally limited due to potential side effects on local tissues. The goal of this intervention is to break the cycle of pain and inflammation, allowing the patient to fully engage with their ongoing physical therapy program.
In rare, select cases, other specialized interventions may be considered if muscle bulk is thought to be a contributing factor to the compression. For example, some specialists may use botulinum toxin injections to temporarily relax specific muscles, like the supinator, that are thought to be actively compressing the nerve. However, this remains a less common approach than localized steroid injections.
Surgical Decompression and Post-Operative Care
Surgical decompression is reserved as a final option for individuals whose pain remains severe and debilitating after a minimum of three to six months of comprehensive non-operative management. The procedure, known as radial tunnel release, aims to free the radial nerve from constrictive tissues, such as fibrous bands or the leading edge of the supinator muscle (the Arcade of Frohse). The surgeon releases these structures to alleviate mechanical pressure.
Following surgery, the arm is typically immobilized in a splint that holds the elbow slightly flexed with the wrist gently extended to protect the surgical site and the decompressed nerve. Immediate post-operative care involves diligently moving the fingers and shoulder to maintain range of motion and prevent stiffness. Wound care and managing post-operative swelling are the initial priorities.
Post-operative physical therapy begins within one to two weeks, focusing first on gentle range-of-motion exercises to prevent the formation of scar tissue around the nerve. Strengthening exercises are gradually introduced around six weeks after surgery, starting at a much lower intensity than pre-operative rehabilitation. Full recovery and return to unrestricted heavy activity can take anywhere from six to eight months, though the prognosis for significant pain relief following successful decompression is generally favorable.