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1Staff Occupational Therapist, Shinoro Orthopedic, Hokkaido, Japan; PhD candidate, Sapporo Medical University, The Graduate School of Health Sciences, Department of Occupational Therapy, Hokkaido, Japan. 3PhD candidate, The University of Queensland, School of Health and Rehabilitation Science, Division of Physiotherapy, Queensland, Australia. The patients reported in this study were seen and treated at the Shinoro Orthopedic. All patients provided informed consent to be included in this case series and their anonymity was guaranteed. The opinions or assertions contained herein are the private views of the authors. The authors affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. Address correspondence to Hiroshi Takasaki, Division of Physiotherapy, School of Health and Rehabilitation Science, The University of Queensland, Brisbane, Queensland 4072, Australia. E-mail: h.takasaki@uq.edu.au

Intersection syndrome, an overuse injury affecting the forearm, has been reported in sporting activity involving the upper limb, such as rowing, canoeing, racket sports, weight lifting, and skiing.16 People who have intersection syndrome report pain, crepitus,

and/or swelling in the dorsal forearm, 4 to 8 cm proximal to Lister’s tubercle,4 where the muscle bellies of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) cross the underlying extensor

carpi radialis longus (ECRL) and exten-sor carpi radialis brevis (ECRB).5 The pathophysiological basis for intersection

! STUDY DESIGN: Case series.

! BACKGROUND: Intersection syndrome is an overuse injury of the forearm. Taping has been de-scribed for the management of soft tissue injuries, yet there has been no report for the management of intersection syndrome using this method. The purpose of this case series was, therefore, to describe the efficacy of taping for the management of intersection syndrome.

! CASE DESCRIPTION: Five patients with inter-section syndrome were managed by taping, in an effort to reduce crepitus induced by thumb move-ments. Nonstretch sports tape was applied, with an ulnarly directed tension force across the dorsal aspect of the forearm. Taping was performed daily for 3 weeks. Follow-up took place at 1, 2, 3, and 4 weeks, and at 1 year from the initial consultation.

! OUTCOMES: All patients demonstrated com-

plete elimination of crepitus with the application of tape. Crepitus induced by wrist movements, ten-derness over the dorsal forearm, and swelling were no longer present at 3-week follow-up. Disability identified by the disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand questionnaire decreased at 3-week follow-up, and this reduction was maintained at 4-week and 1-year follow-ups.

! DISCUSSION: Taping improved symptoms and function in this small case series. One possible explanation for this improvement may be the alteration of soft tissue alignment.

! LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2011;41(7):514-519, Epub 6 April 2011. doi:10.2519/jospt.2011.3569

! KEY WORDS: overuse syndrome , tape, thumb, wrist

SHOUTA KANEKO, OT, MSc1 • HIROSHI TAKASAKI, PT, MSc2

Forearm Pain, Diagnosed as Intersection Syndrome,

Managed by Taping: A Case Series

syndrome is uncertain, but 2 potential mechanisms are considered. The first may be friction between the tendons of

the APL and EPB, and those of the ECRL and ECRB; the second may be stenosis, due to entrapment within the second dorsal compartment that houses the ECRL and ECRB.4,10,20 Aso et al1 argued in support of the former mechanism, due to the presence of pain on palpation and crepitus over the intersection of the APL and EPB, and the ECRL and ECRB, rather than the distal area of the second dorsal compartment, and due to thumb movements that accompany crepitus. A key feature of intersection syndrome on magnetic resonance imaging (MRI) is peritendinous edema around the first and second extensor compartment ten-dons, which extends proximally from the intersection between the APL and EPB, and the ECRL and ECRB.4,14

Current management of intersection syndrome comprises a combination of rest, nonsteroidal anti-inflammatory drugs, and splinting.10,16 One report in-dicated that 60% of patients responded to this form of management within 2 to 3 weeks.4 However, splinting the wrist in 15° to 20° of extension restricts wrist and thumb movements, possibly leading to difficulty with daily living and work activities.10 Steroid injection is recom-mended for those failing to respond to

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conservative management.10,16

Mulligan15 suggests that tape can be used to reduce pain and enhance heal-ing for Achilles tendinopathy by alter-ing the direction of forces across the muscle-tendon unit. If tendon friction is the predominant cause of intersection syndrome, as Aso et al1 propose, then the taping technique as described by Mul-ligan across the APL and EPB tendons may change the mechanical force around the painful area, decreasing friction, and resulting in less pain, while assisting healing processes.

We used the conceptual paradigm proposed by Mulligan as a new form of management for intersection syndrome. The purpose of this case series is to de-scribe the use of tape for the management of intersection syndrome in 5 patients.

CASE DESCRIPTIONS

Five female patients (mean age, 49.4 years), referred to physiother-apy with a diagnosis of intersection

syndrome, were managed with taping. The right arm was symptomatic in 4 and the left arm in 1 of the patients. Pa-tient demographics are summarized in TABLE 1. These data include duration and predominant side of symptoms, presence of crepitus induced by active wrist move-ments, swelling along the course of the affected tendons, and tenderness over the dorsal forearm for each patient. Pain at rest and raised skin temperature were not seen in any of the patients.

An orthopaedic surgeon diagnosed intersection syndrome, based on physi-cal assessments, including Finkelstein’s test, isometric muscle testing of the APL, EPB, ECRL, and ECRB, Tinel’s sign, up-per limb neurodynamic tests, and the overall clinical presentation (tenderness over the dorsal forearm, 4 to 8 cm proxi-mal to the wrist joint, crepitus induced by active wrist movements, and visible swelling along the course of the affected tendons). Diagnosis was also made with MRI, by identifying peritendinous ede-ma around the first and second extensor

compartment tendons, extending proxi-mally from the intersection between the APL and EPB, and the ECRL and ECRB.4 All patients in this case series had re-quested not to be treated with a hand splint, due to the hindrance of the splint for their work. Consequently, the patients were deemed suitable for a trial of taping, and volunteered for this intervention af-ter being informed of the available treat-ment options.

All patients demonstrated limited range of motion for active and passive flexion at the metacarpalphalangeal (MP) joint of the thumb, passive wrist flexion, and active wrist extension, as measured by a goniometer (TABLE 2). Fin-kelstein’s test was positive in each case. Finkelstein’s test is most commonly as-sociated with De Quervain’s disease; but other instances of radial-sided wrist and

distal forearm pain, such as intersection syndrome, wrist injuries, and entrap-ment neuropathy of the superficial radial nerve, can be provoked by the Finkel-stein’s test maneuver.9,12 However, pain was also provoked by isometric muscle testing of the ECRL or ECRB, but not for the APL or EPB, suggesting the presence of intersection syndrome rather than De Quervain’s disease.3 Furthermore, ten-derness was found on the dorsal forearm rather than along the radial aspect of the wrist,6 which is a clinical picture differ-ent from that of De Quervain’s disease. Moreover, crepitus during active thumb movements was found on the intersec-tion between the APL and EPB, and the ECRL and ECRB, on the dorsal forearm, in contrast to crepitus found over the first dorsal compartment or at the styloid pro-cess of the radius in individuals with De

TABLE 1 Demographic Information

Abbreviations: +, present; F, female; L, left; R, right.*Crepitus induced by thumb movements.†Swelling was visually estimated from a comparison with the opposite side.‡Tenderness was present based on pressure pain over the dorsal forearm rated at 3 or more on an 11-point numeric rating scale (0, no pain; 10, pain as bad as it could possibly be).

Variable Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Age, y 44 50 50 50 53

Gender F F F F F

Dominant hand R R R R R

Painful hand L R R R R

Employment Homemaker Nursing care Nursing care Cleaning Nursing care

Symptom duration, d 90 45 30 14 21

Crepitus* + + + + +

Swelling† + + + + +

Tenderness‡ + + + + +

TABLE 2Range of Motion of the MCP Joint of the Thumb and the Wrist Joint*

Abbreviation: MCP, metacarpalphalangeal.*Range of motion on the pain-free side provided in parentheses.

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Active MCP flexion 40° (55°) 45° (55°) 45° (60°) 45° (60°) 40° (60°)

Passive MCP flexion 45° (55°) 45° (55°) 50° (60°) 50° (60°) 50° (60°)

Active wrist extension 45° (70°) 50° (65°) 50° (70°) 60° (70°) 55° (70°)

Passive wrist flexion 60° (85°) 65° (85°) 60° (90°) 70° (90°) 60° (90°)

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Quervain’s disease.3 These findings indi-cated less possibility of the presence of De Quervain’s disease. In addition, in each of our patients, the Tinel’s sign and upper limb neurodynamic tests suggestive of entrapment neuropathy of the superficial radial nerve2,9 were negative.

TABLE 3 summarizes functional dis-ability for each patient and pain inten-sity prior to the application of taping at the initial consultation. Pain intensity

was measured with an 11-point numeri-cal rating scale (NRS), and functional scores measured with the disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand question-naire, Japanese version (DASH-JSSH disability/symptom), for which reliabil-ity and validity have been established.11 All patients provided informed consent for publication and their anonymity was guaranteed.

Taping TechniqueA generic, 50-mm-wide nonstretch tape (Battlewin C50F; Nichiban Co, Ltd, To-kyo, Japan) was utilized in this study. The taping direction for each patient was determined by assessing crepitus during thumb movements, while manual force was applied across the soft tissue of the dorsal aspect of the forearm. A reduction of crepitus, when force was applied in ei-ther the ulnar or radial direction, indicat-ed a positive response, which determined the taping direction to be used. Tape was then applied in an attempt to replicate and maintain the manually applied force across the muscle-tendon unit. The dis-tal end of the tape was applied first to the muscle bellies of the APL and EPB. Tension was exerted with the free end of the tape as it was applied across the dorsal forearm, perpendicular to its long axis (FIGURE 1). A second layer of tape was used to reinforce the first layer. Reevalu-ation of thumb movement was performed to ensure the effectiveness of the tape in eliminating crepitus induced by active thumb movements. If crepitus remained, the tape direction or tension force was al-tered slightly until no crepitus was per-ceived. Once the specific taping direction and tension force were determined, each patient was instructed in self-application of the tape.

The tape was removed at night, and each patient was instructed to maintain the taping regimen for 3 weeks and al-lowed to continue work. Patients were advised to reapply the tape if the effects of taping were not optimal and to stop taping if they had any adverse skin reac-tion, of which there were none during the treatment period. The patients were also advised to perform their normal daily activities. Following the 3-week inter-vention, all patients were advised to use the symptomatic limb during activities of daily living and to work without tape. They were instructed to reapply the tape if they had any return of symptoms.

Outcome MeasuresOutcome measures included the pres-

TABLE 3

Most Painful Activity, Pain Intensity During This Activity, and Functional

Outcome Score Prior to the Application of Taping at the Initial Consultation

Abbreviation: DASH-JSSH disability/symptom, disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand questionnaire, Japanese version.*Measured by an 11-point numeric pain scale (0, no pain; 10, pain as bad as it could possibly be).†A high score indicates poor upper limb function.

Patient Most Painful Activity Pain During the Activity* DASH-JSSH Disability/Symptom†

1 Squeezing 9 59.2

2 Transferring 8 46.7

3 Transferring 9 67.8

4 Squeezing 10 75.0

5 Cooking 8 70.0

FIGURE 1. Taping over the dorsal forearm with an ulnarly directed tension force. Abbreviations: APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EPB, extensor pollicis brevis.

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ence of crepitus induced by active thumb movements with no tape application, tenderness over the dorsal forearm (3 or more on the NRS), swelling, and functional disability as measured by the DASH-JSSH disability/symptom. As-sessments were taken at the initial evalu-ation, prior to the initial application of tape, and at the follow-up points of 1, 2, 3, and 4 weeks. In addition, 1 year following the initial assessment, each patient was assessed with the DASH-JSSH disability/symptom via phone interview.

OUTCOMES

In all patients, crepitus induced by thumb movement was diminished or reduced by the manual application of

an ulnarly directed force on the soft tis-sues of the dorsal forearm, as force ap-plied in the opposite (radial) direction produced no change. In addition, crepi-tus was resolved by taping across the dorsal forearm with an ulnarly directed force in all patients. Movement was less painful when the tape was applied, and all patients reported that the symptom-relieving effects of taping lasted through-out the day, making reapplication of the tape unnecessary.

At 3-week follow-up, all patients re-ported the absence of crepitus induced by thumb movements. In addition, other findings were no longer present, includ-ing swelling and tenderness over the dorsal forearm (TABLE 4). FIGURE 2 demon-strates the scores on the DASH-JSSH dis-ability/symptom at each follow-up point for each patient. There was considerable improvement in upper limb function at the 3-week follow-up in all patients, as evidenced by change in DASH-JSSH dis-ability/symptom scores. At the 4-week follow-up, the DASH-JSSH disability/symptom score in each patient was not different from that of the 3-week follow-up, and all patients noted neither repro-duction of pain during functional activity nor limited range of motion of the thumb and wrist. Consequently, patients were discharged from physiotherapy. All pa-

tients maintained pain-free normal up-per limb function at 1-year follow-up.

DISCUSSION

This case series suggests the ben-eficial effects of taping for the man-agement of intersection syndrome.

It should be noted that the taping tech-nique reported in this study is unlikely to be effective for other forearm pain syn-dromes, such as De Quervain’s disease and entrapment neuropathy of the su-perficial radial nerve, due to differences in underlying pathophysiology. Hence,

an accurate diagnosis of intersection syndrome is important to identify those likely to respond to this form of manage-ment. In the current case series, a com-prehensive physical examination and MRI were used to establish the diagnosis of intersection syndrome.

All patients experienced rapid im-provement of upper limb function with the application of tape, despite the dura-tion of symptoms having been present for up to 90 days in 1 patient. Although this finding suggests the positive effect of taping in individuals with intersection syndrome, a cause-and-effect relation-

TABLE 4

The Presence or Absence of Crepitus Induced by Active Thumb Movements, Swelling, and

Tenderness Over the Dorsal Forearm Without Taping at Each Follow-up Point for Each Patient

Abbreviations: +, present; –, absent.*Swelling was visually estimated from a comparison with the opposite side.†Tenderness was present based on pressure pain over the dorsal forearm rated at 3 or more on the 11-point (0-10) numeric rating scale.

Patient/MeasuresInitial

Consultation 1-wk Follow-up 2-wk Follow-up 3-wk Follow-up 4-wk Follow-up

Patient 1

Crepitus + + + – –

Swelling* + + – – –

Tenderness† + + + – –

Patient 2

Crepitus + + + – –

Swelling + + – – –

Tenderness + + + – –

Patient 3

Crepitus + + + – –

Swelling + – – – –

Tenderness + + + – –

Patient 4

Crepitus + + + – –

Swelling + – – – –

Tenderness + + – – –

Patient 5

Crepitus + + – – –

Swelling + – + – –

Tenderness + + + – –

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REFERENCES

1. Aso K, Tada K, Torisu T, Masumi S. Pathologic anatomy of the intersection syndrome. J Jpn Soc Surg Hand. 1996;13:186-188.

2. Carlson N, Logigian EL. Radial neuropathy. Neu-rol Clin. 1999;17:499-523, vi.

3. Cooper C. Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. St Louis, MO: Mosby Elsevier; 2007.

4. Costa CR, Morrison WB, Carrino JA. MRI fea-tures of intersection syndrome of the forearm. Am J Roentgenol. 2003;181:1245-1249.

5. de Lima J, Kim H, Albertotti F, Resnick D. Inter-section syndrome: MR imaging with anatomic comparison of the distal forearm. Skeletal Ra-diol. 2004;33:627-631.

6. Dvorak J, Dvorak V, Gilliar W, Schneider W, Spring H, Tritschler T. Musculoskeletal Manual Medicine: Diagnosis and Treatment. New York, NY: Thieme; 2008.

7. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009;68:1843-1849. http://dx.doi.org/10.1136/ard.2008.099572

8. Gonzalez-Iglesias J, Fernandez-de-Las-Penas C, Cleland JA, Huijbregts P, Del Rosario Gutierrez-Vega M. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a random-ized clinical trial. J Orthop Sports Phys Ther. 2009;39:515-521. http://dx.doi.org/10.2519/jospt.2009.3072

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ship cannot be established from a case series. Some studies have demonstrated a positive effect of taping on pain reduc-tion,8,17-19 and Mulligan15 suggests that this positive effect of taping on pain reduction and soft tissue healing may be related to the alteration of soft tissue biomechan-ics. Yet the ability of taping to change the alignment of anatomical structures is debatable.13 In the current case series, all patients experienced reduction of crepi-tus induced by thumb movements when a force to shift the skin was applied manu-ally. This suggests that taping might in-duce alteration of soft tissue alignment of the APL, EPB, ECRL, and/or ECRB. Nev-ertheless, it is uncertain whether taping actually changes soft tissue alignment, particularly when these muscles are con-tracting. MRI evaluation of muscle align-ment before and during taping would be necessary to support such a hypothesis. In addition, 5 is an insufficient number of patients to clearly establish that an ulnarly directed force is necessary to ob-tain reduction or disappearance of the crepitus in patients with this condition.

Further studies with bigger sample sizes would be required to confirm this finding.

All patients demonstrated consider-able improvement of upper limb function over the 3-week taping period, as well as maintenance of upper limb function at the 1-year follow-up. This indicates the potential usefulness of taping for the management of intersection syndrome. In future clinical studies, it would be in-teresting to compare the effectiveness of taping to other treatment approaches, such as splint therapy and steroid injec-tion, in terms of time to recovery, cost ef-fectiveness, quality of life, satisfaction of treatment, long-term functional ability of the upper limb, and recurrence rate. For example, splint therapy restricts normal wrist/hand movements10 and may lead to a decrease in quality of life and/or low satisfaction with treatment. Also, in the management of shoulder and elbow tendinitis, steroidal injection has poorer long-term outcomes in pain and physical function than conservative treatments without injection.7 With these consider-ations, taping may be a useful approach

for intersection syndrome.It should be noted that there may be

more effective taping approaches than the technique reported here. We did not compare different methods of tap-ing, for example, different tape width, length, and properties (eg, stretch or nonstretch). These points merit further investigation to find the optimal applica-tion of tape in the management of inter-section syndrome. !ACKNOWLEDGEMENTS: The authors acknowl-edge Yoshikazu Ikemoto, MD, PhD for dif-ferential diagnosis and Toby Hall, PT, MSc, FACP for reviewing the manuscript prior to submission.

0

10

20

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60

70

80

90

100

1-wk Follow-upInitial Consultation

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

2-wk Follow-up 3-wk Follow-up 4-wk Follow-up 1-y Follow-up

FIGURE 2. Scores on the disability/symptom subscale of the Disabilities of the Arm, Shoulder and Hand questionnaire, Japanese version at each follow-up point for each patient. Scores on the scale range from 0 to 100, with higher scores indicating greater disability.

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@ MORE INFORMATIONWWW.JOSPT.ORG

368. http://dx.doi.org/10.2519/jospt.2010.3210 10. Hanlon DP, Luellen JR. Intersection syndrome: a

case report and review of the literature. J Emerg Med. 1999;17:969-971.

11. Imaeda T, Toh S, Nakao Y, et al. Validation of the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoul-der, and Hand questionnaire. J Orthop Sci. 2005;10:353-359. http://dx.doi.org/10.1007/s00776-005-0917-5

12. Kaneko S, Takasaki H, May S. Application of mechanical diagnosis and therapy to a patient diagnosed with de Quervain’s disease: a case study. J Hand Ther. 2009;22:278-283; quiz 284. http://dx.doi.org/10.1016/j.jht.2009.03.002

13. Larsen B, Andreasen E, Urfer A, Mickelson MR, Newhouse KE. Patellar taping: a radiographic examination of the medial glide technique. Am J

Sports Med. 1995;23:465-471. 14. Lee RP, Hatem SF, Recht MP. Extended MRI find-

ings of intersection syndrome. Skeletal Radiol. 2009;38:157-163. http://dx.doi.org/10.1007/s00256-008-0587-4

15. Mulligan BR. Manual Therapy NAGS SNAGS MWMS etc. 5th ed. Minneapolis, MN: Orthopedic Physical Therapy Products; 2006.

16. Servi JT. Wrist pain from overuse: detecting and relieving intersection syndrome. Phys Sportsmed. 1997;25:41-44. http://dx.doi.org/10.3810/psm.1997.12.1401

17. Thelen MD, Dauber JA, Stoneman PD. The clini-cal efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial. J Orthop Sports Phys Ther. 2008;38:389-395. http://dx.doi.org/10.2519/jospt.2008.2791

18. Vicenzino B, Brooksbank J, Minto J, Offord

S, Paungmali A. Initial effects of elbow tap-ing on pain-free grip strength and pressure pain threshold. J Orthop Sports Phys Ther. 2003;33:400-407.

19. Wilson T, Carter N, Thomas G. A multicenter, single-masked study of medial, neutral, and lateral patellar taping in individuals with patel-lofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33:437-443; discussion 444-438.

20. Young D, Papp S, Giachino A. Physical exami-nation of the wrist. Hand Clin. 2010;26:21-36. http://dx.doi.org/10.1016/j.hcl.2009.08.010

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