New York State Medical Treatment Guidelines for Radial Nerve Entrapment (Including Radial Tunnel Syndrome) in workers compensation patients

The guidelines crafted by the workers’ compensation board in New York State aim to aid physicians, podiatrists, and healthcare professionals in delivering suitable treatment for Radial Nerve Entrapment, encompassing conditions like Radial Tunnel Syndrome.

These guidelines from the Workers Compensation Board are designed to support healthcare professionals in determining the right level of care for individuals with Radial Nerve Entrapment

It’s crucial to note that these guidelines don’t replace clinical judgment or the expertise of healthcare professionals. The ultimate decision on care should be a collaborative one, made by the patient in consultation with their healthcare provider.

Experiencing aching and soreness in the upper part of the forearm could indicate radial nerve entrapment, especially when it involves the posterior interosseous branch of the nerve. This condition is sometimes referred to as “resistant tennis elbow” or “supinator syndrome,” making it a bit tricky to clinically distinguish from general forearm and elbow pain.

Radial Nerve Entrapment (Including Radial Tunnel Syndrome)

Radial nerve entrapment is considered relatively uncommon, occurring 30 to 100 times less frequently than carpal tunnel syndrome. There are various potential sites where this entrapment can happen.

Commonly affected areas include the origin of the extensor carpi radialis brevis, fibrous bands covering the radial head, the radial recurrent arterial fan, and the arcade of Frohse at the entry to the supinator muscle. Confirming the diagnosis with an electrodiagnostic motor examination is often challenging but recommended.

In the absence of robust data for treating these radiculopathies, it is suggested to draw insights from the treatments recommended for ulnar neuropathy at the elbow, as outlined below.


Medications of Radial Nerve Entrapment (Including Radial Tunnel Syndrome)

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are recommended as the primary choice for the majority of patients. In cases where NSAIDs are not suitable, acetaminophen (or its analogue paracetamol) could be a plausible alternative, even though research suggests it might be slightly less effective than NSAIDs.

Evidence indicates that NSAIDs are not only less risky but also equally effective in alleviating pain compared to opioids like tramadol.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treating Acute, Subacute, Chronic, or Postoperative Pain in Pronator Syndrome Non-Steroidal Anti-inflammatory Drugs (NSAIDs) are advised for addressing postoperative, chronic, or subacute pain associated with Pronator Syndrome.

Indications – NSAIDs are recommended for managing pain related to postoperative Pronator Syndrome, chronic pain, or subacute pain. Over-the-counter medications should be attempted first, as they may prove effective.

Frequency/Duration – Using NSAIDs as needed might be suitable for many patients.

Indications for Discontinuation – Discontinuation may be warranted if elbow pain diminishes, if the treatment proves ineffective, or if side effects emerge.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is suggested, and a combination of misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors is often used in individuals with a high risk of gastrointestinal bleeding.

Indications – Cytoprotective drugs should be considered for patients with a high-risk profile who need NSAIDs, especially for an extended treatment period. Those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers are particularly at risk.

Frequency/Dose/Duration – H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are recommended, following the manufacturer’s dosage guidelines. Generally, there’s a consensus that these measures are equally effective in preventing gastrointestinal bleeding.

Indications for Discontinuation – Discontinuation may be necessary due to intolerance, the onset of adverse effects, or if NSAIDs are discontinued.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is suggested, with acetaminophen or aspirin considered the safest first-line therapy in terms of cardiovascular impact. If needed, non-selective NSAIDs are recommended over COX-2-specific medications. To avoid compromising the protective effects of low-dose aspirin in individuals using it for cardiovascular disease prevention, NSAIDs should be taken at least 30 minutes after or eight hours before the daily aspirin.

Acetaminophen for Alleviating Elbow Pain is suggested for managing discomfort in the elbow, especially for individuals with contraindications to NSAIDs.

Indications – Applicable to all patients, including those experiencing acute, subacute, chronic, and post-operative elbow pain.

Dose/Frequency – Follow the manufacturer’s recommendations; use as needed. Caution is advised, as evidence suggests potential liver toxicity with doses exceeding four grams per day.

Indications for Discontinuation – Cease usage when pain subsides, side effects arise, or intolerance is observed.

Glucocorticosteroids – Oral or Injections are not recommended for acute, subacute, or persistent radial nerve entrapment.

Opioids for Radial Nerve Entrapment (Including Radial Tunnel Syndrome) are not recommended for managing persistent or subacute discomfort associated with radial nerve entrapment.

Opioids for Radial Nerve Entrapment (Including Radial Tunnel Syndrome) are suggested for a limited period, up to one week, to control radial nerve pain post-surgery.

Rationale for Recommendations – Opioids lack sufficient research for treating radial nerve entrapment and pose significant side effects, including poor tolerance, constipation, drowsiness, impaired judgment, memory loss, and potential dependence (reported in up to 35% of patients).

Patients should be cautioned against operating machinery or vehicles and informed about potential side effects before receiving an opioid prescription. Safer analgesics are generally effective for most musculoskeletal complaints, and opioids should be reserved for extreme pain or brief postoperative use (no longer than one week). They are not recommended for prolonged treatment of radial nerve entrapment.

Vitamins are recommended for acute, subacute, or chronic radial nerve entrapment, particularly pyridoxine.

Lidocaine Patches are recommended for managing acute, subacute, or ongoing discomfort associated with radial nerve entrapment.

Ketamine is recommended for acute, subacute, or persistent radial nerve entrapment.

Treatments of Radial Nerve Entrapment (Including Radial Tunnel Syndrome)

Rehabilitation: Therapy / Equipment

Post-injury rehabilitation, especially following a work-related incident, should focus on restoring the functional capabilities necessary for the patient’s daily and work responsibilities, aiming to facilitate a return to their pre-injury status as much as practically possible.

Active therapy requires the patient to invest internal effort in completing specific activities or tasks, while passive therapy involves modalities administered by a therapist without the patient actively participating.

Passive therapies are generally viewed as a means to expedite an active therapy program, achieving concurrent functional gains. However, priority should be given to active initiatives over passive interventions.

To maintain and build on improvements, it’s crucial for the patient to continue both active and passive therapies at home as a natural extension of the therapeutic journey.

The integration of assistive devices can be beneficial as a supplementary measure in the overall rehabilitation strategy to enhance functional gains.

Therapy (Active and Passive) Physical or Occupational Therapy for Acute, Subacute, Chronic, or Postoperative Radial Nerve Entrapment For individuals dealing with Radial Nerve Entrapment, whether it’s post-operative, chronic, subacute, or acute, it’s advisable to undergo Physical or Occupational Therapy.

Frequency/Dose/Duration – The total number of therapy sessions can vary, ranging from two to three for those with minor deficits to 12 to 15 for those with more severe issues, depending on continued objective functional progress.

If there’s evidence of improvement toward specific functional goals, like enhanced grip strength or improved range of motion, more than 12 to 15 sessions might be necessary to address persistent functional impairments.

Incorporating a home exercise routine into the rehabilitation plan is essential and should be consistently followed alongside therapy.

Indications for Discontinuation – Therapy can be stopped when elbow discomfort resolves, intolerance is experienced, there’s a lack of effectiveness, or non-compliance, including failure to perform recommended at-home exercises.

Magnets Magnets are recommended for acute, subacute, or persistent radial nerve entrapment.

Elbow and Wrist Splinting Utilizing Elbow and Wrist Splints is advised for acute, subacute, or persistent radial nerve entrapment.


Acupuncture, Biofeedback, Manipulation and Mobilization, Massage, Soft Tissue Massage, Iontophoresis, Phonophoresis These therapies, including Acupuncture, Biofeedback, Manipulation and Mobilization, Massage, Soft Tissue Massage, Iontophoresis, and Phonophoresis, are not recommended for sudden, gradual, or persistent radial nerve entrapment.

Low-Level Laser Therapy Low-Level Laser Therapy is not recommended for acute, subacute, or chronic radial nerve entrapment.

Ultrasound Ultrasound is recommended for acute, subacute, or chronic radial nerve entrapment.

Surgery of radial Nerve Entrapment (Including Radial Tunnel Syndrome)

Referrals for Radial Nerve Operations In certain cases, referrals for radial nerve operations may become necessary, especially for patients displaying significant warning signs, like compressive neuropathy following an acute fracture, or those showing no improvement with non-surgical approaches, such as the use of wrist splints.

The decision for surgery hinges on a well-established diagnosis of the symptoms. It’s vital to provide comprehensive counseling about potential outcomes, associated risks, benefits, and, most importantly, realistic expectations when contemplating surgery.

Setting clear expectations pre-surgery regarding the importance of adhering to the rehabilitative exercise routine and managing post-operative pain is crucial. To prevent complications like frozen shoulder (adhesive capsulitis), post-operative range-of-motion exercises should target the elbow, wrist, and shoulder.

Surgical Release for Treating Subacute or Chronic Radial Neuropathies Surgical release is recommended for individuals with urgent indications, such as acute compression resulting from a fracture or compartment syndrome with persistent nerve damage symptoms, who have not responded to non-operative treatments for subacute or chronic radial neuropathies.

Indications – Presence of symptoms related to radial neuropathy in the elbow, significant loss of function evidenced by considerable activity limitations due to nerve entrapment, and a lack of response to nonoperative treatments, typically spanning three to six months. Patients are generally expected to fully comply with therapy, use failing wrist splints, and avoid aggravating factors.

Early candidates for surgery may include those with persistent tingling and numbness, worsening symptoms, or functional impairment. Some surgeons may hesitate to operate if electrodiagnostic results are negative.

The choice of surgical treatment is influenced by factors like preoperative electrodiagnostic investigations, the surgeon’s expertise and comfort level, and the specific surgical anatomy.

What our office can do if you have workers compensation injuries causing Radial Nerve Entrapment

If you’ve suffered from workers compensation injuries leading to Radial Nerve Entrapment, our office is well-equipped to provide the support you need. With our extensive experience, we’re here to assist you through the challenges of workers compensation cases. We empathize with the difficulties you’re facing and are committed to addressing your medical requirements while adhering to the guidelines established by the New York State Workers Compensation Board.

Recognizing the significance of your workers compensation cases, we aim to guide you through the complexities of dealing with both the workers compensation insurance company and your employer. We understand that this period can be stressful for you and your family, and our goal is to make it as manageable as possible. If you wish to schedule an appointment, please reach out to us. We are dedicated to doing everything within our means to support you during this time.

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