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Intersection Syndrome

Introduction

Intersection syndrome is a condition that affects the first and second compartments of the dorsal wrist extensors. The condition is thought to occur as a result of repetitive friction at the junction in which the tendons of the first dorsal compartment cross over the second, creating tenosynovitis. 

The term “intersection syndrome” refers to the intersection (at an angle of around 60°) of the musculotendinous junctions of the first and second extensor compartment tendons.

The intersection syndrome is a relatively uncommon disorder that is often misdiagnosed with other conditions, such as ‘De Quervain’s tenosynovitis.

Epidemiology

  • The syndrome is typically the result of repetitive extension and flexion exercises or activities.
  • It is commonly seen in sporting activities such as rowing or canoeing, skiing, racquet sports, and horseback riding.
  • There is no significant difference in injury pattern found in men versus women

Examination/Clinical Presentation

Look for

  • Swelling over the distal forearm as there can be some cases that present with a palpable finding on exam 4 cm - 6 cm proximal to Lister's tubercle.
  • Crepitus is a very common finding on the exam over the site of irritation (a finding that is specific to intersection syndrome).
  • The two dorsal compartments cross the movements of pronation and supination, create friction resulting in the exam finding of crepitus.
  • Pronation is typically found more uncomfortable than supination.
  • The Finkelstein’s test resulted in uneasiness. The Finkelstein’s test is a passive stretch test with ulnar abduction and flexion of the thumb.
  • Intersection syndrome is a clinical diagnosis, although a musculoskeletal ultrasound can easily confirm it. Ultrasound technology has pushed musculoskeletal medicine forward in both diagnosis and treatment provided by physicians.
  • Plain film imaging and CT will not be helpful in the diagnosis of Intersection syndrome.
  • MRI would give excellent soft-tissue picture and diagnosis, although MRI would not be a cost- or time-effective choice.

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Differential Diagnosis

De Quervain tenosynovitis: Clinicians often misdiagnose it as De Quervain tenosynovitis (first extensor compartment involvement only, located more distal at the radial styloid).

  • Muscle strain
  • Wartenberg’s syndrome: Entrapment of the dorsal radial sensory nerve as it emerges beneath the brachioradialis
  • Thumb CMC arthritis
  • Extensor pollicis longus (EPL) tendinitis

Medical Management

Treatment is conservative management with rest and activity modification.

Conservative/Non-operative Treatment:

Rest, splinting, activity modification along with anti-inflammatory medications for pain relief are the first line of treatment. Common medications are ibuprofen, naproxen, meloxicam or diclofenac. Acetaminophen are prescribed for pain relief. Corticosteroid injection has shown significant improvement and is a known next best step if little or no improvement has been made with other conservative treatment.

Surgical Treatment:

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

Physical Therapy Management

The intersection syndrome is usually managed conservatively.

  • Activity Modification: The first step of this management includes modification of work and sport activities, which will help to reduce stress on the wrist and splinting.
  • Ice: Local ice-pack placement can help in relieving pain.
  • Splinting: A temporary splint for protection and comfort at night may also be beneficial (a neutral position with a splint), an activity change and anti-inflammatory medication is normally appropriate to control the symptoms.

Summary

To summarise, intersection syndrome is inflammatory tenosynovitis at the intersection of the 1st dorsal compartment (APL, EPB) and 2nd dorsal compartment (ECRL, ECRB) of the wrist. Although no established evidence-based rehabilitation protocol exists for treating it, addressing symptoms early is necessary to prevent long-term complications. Patients report pain over dorsal forearm and wrist and the examination reveals tenderness over the dorsal radial forearm about 4-6 cm proximal to joint, worse with resisted wrist extension, thumb extension. The diagnosis is primarily clinical but supported by US and MRI and the treatment is primarily conservative, which includes splinting, rest, activity modification, ice, acetaminophen for pain relief, and splinting for protection and very rarely surgical debridement or release.

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