Intersection syndrome

Original Editors - Emilie Depasse

Top Contributors - Emilie Depasse, Evan Thomas and Wanda van Niekerk

Search Strategy

Key words : Intersection syndrome, crossover syndrome, forearm pain, treatment

Consulted databases: Pubmed, Web of knowledge and the medical library of the VUB


Definition/Description

Intersection syndrome is an overuse disorder of the dorsal distal forearm. [1] [6] Usually it appears after a recent change in activity or a long period of repetitive activity using continuously flexion and extension or radial abduction. [2] [3] The intersection syndrome is a relative uncommon disorder that is often misdiagnosed with other conditions, such as ‘De Quervain’s tenosynovitis. [2]’ The site of abnormality is the area of intersection between the first and the second dorsal compartment in the dorsoradial aspect of the distal forearm. The name “intersection syndrome” was first induced by Dobyns et al, but Velpeau was the first describing ‘The Intersection Syndrome’ (1841). [6]The same condition has been described by many other terms, like peritendinitis crepitans, bugaboo forearm, crossover syndrome, adventitial bursitis, subcutaneous perimyositis, oarsman’s wrist and abductor pollicis longus syndrome. [2]


Clinically Relevant Anatomy

The location of inflammation describes the region 4-8 cm proximal to Lister’s tubercle. [1] [2] [3] The
M. extensor carpi radialis longus (ECRL) and the M. extensor carpi radialis brevis (ECRB) tendons, which are part of the second dorsal extensor compartment of the wrist, cross the M. abductor pollicis longus (APL) and the M. extensor pollicis brevis (EPB) tendons, which includes the first dorsal extensor tendon compartment, at an angle of approximately 60°.[4] [6]The site of abnormality is located where these 2 dorsal extensor compartments cross each other.

Epidemiology /Etiology

The intersection syndrome is much less common than de Quervain tenosynovitis, the syndrome with which it is most easily confused. Intersection syndrome can be caused by direct trauma to the second extensor compartment. It is more often caused by activities that require repetitive wrist flexion and extension. There is an association with sports-related activities, including rowing, playing racket sports, skiing, weightlifters, motocross riders and horseback riding. [6] [9]

Generally the intersection syndrome was thought to be due to unaccustomed friction between the two tendon compartments, however more recently was demonstrated as tenosynovitis of the second compartment, with adjacent swelling occurring subsequently. [2]

Although authors consider that the intersection syndrome is a consequence of friction between bellies from the first dorsal compartment and the tendons of the second dorsal compartment, others hypothesised that this overuse syndrome was primarily the result of hypertrophy of the bellies of the abductor pollicis longus and the extensor pollicis brevis. Further there are also author’s who wrote that the syndrome could be explained by entrapment from stenosis. [3]

The recent conclusion of this syndrome is a non-infectious tenosynovitis related with overuse bearing in mind the peritendonitis oedema. [3]

Characteristics/Clinical Presentation

Radial wrist or forearm pain are the complaints of patients with the intersection syndrome. Repetitive wrist flexion and extension may exacerbate the symptoms. [2]

Symptoms:

• Pain and swelling in the area of 7 cm of the distal radius
• Erythema
• Edema
• Tenderness to palpation
• Crepitance with flexion and extension of the wrist [2] [3] [4] [6] [7]

Differential Diagnosis

The examiner must exclude other causes of radial forearm pain, such as:


• De Quervain’s tenosynovitis- inflammation of the tendons of m. extensor pollicis brevis (EPB) and the m. abductor pollicis longus (APL). [4]
• Other inflammatory tenosynovitis
• Wrist ligament sprain
• Muscle strain
• Ganglion cyst
• Infection
• Soft tissue neoplasm
• Entrapment of the dorsal radial sensory nerve as it emerges beneath the brachioradialis (Wartenberg’s syndrome)
• Thumb CMC arthritis
• Extensor pollicis longus (EPL) tendinitis

Examination

On examination , swelling at the site of intersection is frequently present. Active or passive wrist motion creates a crepitus.

The Finkelstein’s test resulted in uneasiness. The Finkelstein’s test is a passive stretch test with ulnar abduction and flexion of the thumb. [1] [3][4]


Medical Management


The diagnosis is often made clinically but may be found when wrist and forearm pain is investigated with MRI. [1] [2]

Surgery is only required in case of persisting symptoms after an already adequate course of conservative treatment. [1] [4]

Surgery is contraindicated in patients with vague nonspecific complaints or in those patients who have not received or been compliant with recommended unoperative measures.

Physical Therapy Management

The intersection syndrome is usually managed conservatively.
The first step of this management includes modification of work and sport activities, which will help to reduce stress on the wrist and splinting. Secondly oral nonsteroidal inflammatory medication or local ice-pack placement can also reduce pain. [4]

Conservative management with immobilization (a neutral position with a splint), an activity change and anti-inflammatory medication is normally appropriate to control the symptoms.

A research proved that taping can eliminate crepitus. In this research was found that crepitus induced by wrist movements, swelling and tenderness over the dorsal forearm were no longer present at 3-week follow-up. [5]

The physical therapist will have to start with the conservative treatment. [5]
If there is no change of activity the conservative treatment will not rehabilitate the intersection syndrome. In this case, surgery can be required. [8]

Physiotherapy after a surgical intervention for this syndrome is necessary and can proceed the rehabilitation process. Physical therapy after a surgical intervention includes a process of therapeutic exercises, joint mobilization, scar mobilization, soft tissue massage, stretching and physical agents. Another very important aspect for a worthy rehabilitation contains the patient education concerning activity modification; management of playing an instrument etc. The patient has to maintain a faultless posture for example while using a computer keyboard. [8]

References

1. Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. 2003 Nov;181(5):1245-9. [Level of Evidence: A1]
2. de Lima JE, Kim HJ, Albertotti F, Resnick D. Intersection syndrome: MR imaging with anatomic comparison of the distal forearm. Skeletal Radiol. 2004 Nov;33(11):627-31. Epub 2004 Sep 10. [Level of evidence: A2 ]
3. Descatha A, Leproust H, Roure P, Ronan C, Roquelaure Y. Is the intersection syndrome is an occupational disease? Joint Bone Spine. 2008 May;75(3):329-31. Epub 2007 Aug 31. [Level of evidence: C]
4. Hanlon DP, Luellen JR. Intersection syndrome: a case report and review of the literature. J Emerg Med. 1999 Nov-Dec;17(6):969-71. [Level of evidence: C]
5. Kaneko S, Takasaki H. Forearm pain, diagnosed as intersection syndrome, managed by taping: a case series. [Level of evidence: C ]
6. Lee RP, Hatem SF, Recht MP. Extended MRI findings of intersection syndrome. Skeletal Radiol. 2009 Feb;38(2):157-63. Epub 2008 Sep 23. [Level of evidence: A1]
7. Lui TH, Chow FY. "Intersection syndrome" of the foot: treated by endoscopic release of master knot of Henry. Knee Surg Sports Traumatol Arthrosc. 2011 May;19(5):850-2. Epub 2011 Feb 3. [Level of evidence: C ]
8. Robinson BS, Rehabilitation of a cellist after surgery for de Quervain's tenosynovitis and intersection syndrome, Medical problems of performing artists Volume: 18 Issue: 3 Pages: 106-112 Published: SEP 2003 [Level of evidence: C]
9. Rumball, Jane S.1; Lebrun, Constance M.; Ciacca, Stephen R. Di; Orlando, Karen. Rowing Injuries. Sports Medicine, Volume 35, Number 6, 2005 , pp. 537-555(19)
[Level of evidence: A1]