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Case: 18-year old tennis player with progressing dorsal forearm pain – PART II

March 25, 2010

Review of the Case: An 18-year-old female tennis player presents with a complaint of pain 2 inches or so above the wrist on the dorsoradial aspect.  The problem began approximately 2 months ago as the player was ramping up her training program in preparation for competition.   To date treatment had consisted of ultrasound, IFC, and splinting with an accompanying diagnosis of “tendinitis.”

Manual muscle testing of the patient’s forearm and hand muscles was unremarkable, as were the results of range of motion and orthopedic testing.  Tendon palpation of the surrounding area failed to reproduce pain.  However it was noted that palpation of the area of complaint a ‘creaking’ sensation was noted along with increased tissue tension with movement of the wrist into flexion and extension.  Tissue tension was further increased with passive movement of the first three digits.  No visible swelling or bruising was noted.

Diagnosis:  Intersections Syndrome

A frictional response and possible adventitial bursitis that occurs at the crossing of two groups of tendons:  the Adductor Pollicis Longus & Extensor Pollicis Brevis crossing over the Extensor Carpi Radialis Brevis and the Extensor Carpi Radialis Longus.  Tensile and shearing stresses in the area of the tendons and peritendinous tissues may lead to thickening, adhesions, and cellular proliferation.

The syndrome can be caused by direct trauma to the second extensor compartment.  It is more commonly brought on by activities that require repetitive wrist flexion and extension.  Weightlifters, rowers, and tennis players are particularly prone to this condition.

Physical assessment usually reveals a negative orthopedic testing examination.  Palpatory examination reproduces pain approximately 4-6 cm proximal to Lister’s tubercle that is a palpable nodule on the dorsal aspect of the radius which acts as a pulley for the Extensor Pollicis Longus.  Also noted on palpatory examination is tissue tension/friction when palpating relative motion between the involved structures.

Intersection syndrome is much less common than de Quervain tenosynovitis, which is the syndrome with which it is most easily confused.  De Quervains is a stenosing tynosynovitis of the Abductor Pollicis Longus and Extensor Pollicis Brevis.  The conditions differ in location and often in histological components.  Intersection sydrome is often void of an inflammatory response whilst de Quervains is inflammatory and thus treatment must differ accordingly.


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