The patient presents with pain, tingling, paresthesias over the dorsolateral aspect of the hand, wrist, and fingers.[12][6] The symptoms may extend from the dorsal radial forearm into the thumb, index, and long fingers.[4] Much of the time, they are unable to localize the pain to a specific area. The patient often describes the pain as burning or shooting pain, as opposed to dull and achy pain. They may describe the sensation of numbness and tingling, although this is much rarer. The symptoms may be acute, intermittent, or chronic, which is related to the cause of irritation. Other symptoms can include tenderness, allodynia, dysesthesias, hypoesthesias. Specific motions, including flexion and ulnar deviation of the wrist, exacerbate the symptoms and can be magnified with pinching and gripping through this motion.

Physical Exam[5][11][4][13]:

Visual

• Masses, scars, signs of external compression
• Skin changes

Sensation

• The first dorsal web space is specific to the superficial branch of the radial nerve

Light touch

• May be abnormal
  • Up to 100% of patients

2-point discrimination

• May be abnormal
• 4 to 5 mm greater than the contralateral side or more than 15mm 
  • Up to 80% of patients

Vibration (256 Hz)

• May be abnormal 
  • Up to 100% of patients

Muscle strength

• No motor weakness or signs of atrophy
• May see a decrease in pinch and grip strength due to pain with these activities 
  • Up to 80% of patients

Tinel Test

• Most common finding
• Must test course of the superficial branch of the radial nerve and lateral antebrachial cutaneous nerve
• Identify the nerve segment with maximal Tinel response

Hoffman Test

• Evaluate for upper motor neuron pathology

Finkelstein Test

• May yield a false positive in up to 96% of patients 
• Neuropathy may coexist with de Quervain tenosynovitis

Dellon Test

• Active, forceful hyperpronation of the forearm and ulnar deviation and flexion of the wrist with the elbow extended by the side

Wartenburg's Neuritis Compression Test

• Direct pressure at the insertion of the brachioradialis

Superficial Branch of the Radial Nerve Compression Test

• Direct pressure at junction of brachioradialis and extensor carpi radialis longus causes symptoms

Optional Examination with Nerve Block:

Superficial branch of the radial nerve block with a local anesthetic

• Inject local anesthetic subcutaneously near the area of maximal Tinel Test
• Ultrasound guidance preferred to avoid nerve injury 
• Finkelstein Test should become negative
• Measured pinch and grip strength should improve

Multiple diagnostic modalities can be used to evaluate for cheiralgia paresthetica. They include the following[14][6][14]:

Electromyography/Nerve Conduction Study

• Able to identify slowing nerve conduction velocities as compared to accepted normal values  
• Commonly there is no slowing present
• Very helpful if present. May be able to identify the location and nature of nerve injury precisely

Ultrasound

• Can help distinguish between the different causes of wrist pain including cheiralgia paresthetica, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis
• Able to identify areas of nerve entrapment or compression

Plain Radiographs

• Able to identify any bony prominences or orthopedic hardware present

Magnetic Resonance Imaging

• T1-weighted images can identify the nerve anatomy including any narrowing or enlargement that may be caused by its entrapment
• Water sensitive sequences including fat-suppressed T2-weighted, fat-suppressed proton density-weighted, and short tau inversion recovery (STIR) images can identify changes in the nerve itself including edema and enhancement

Management of cheiralgia paresthetica is mainly nonoperative therapy. Attention should first focus on removing sources of external compression that could be leading to the neuropathy. The patient should be encouraged to rest, avoid any provocative maneuvers, and alter any work activities that may exacerbate the symptoms. Also, NSAIDs and nerve medications can be used to augment therapy.[4] In refractory cases, temporary thumb spica splinting and ultrasound-guided corticosteroid injections are optional additions to the treatment regimen.[15] Underlying medical problems that may compound the symptoms require assessment and treatment. Reports are that up to 71% of patients treated nonoperatively have good to excellent outcomes.[4]

Surgery is only for failure of nonoperative treatment. Treatment should be attempted for 6 months before one proceeds with surgical intervention. Clinicians require caution when treating patients with painless paresthesias as surgical complications may create painful neurologic symptoms.[4] There are a number of surgical techniques described; many of these focus on the superficial branch of the radial nerve itself, including neurolysis, endoscopically assisted neurolysis,[16] neurolysis and nerve wrapping with material such as amniotic membranes and temporoparietal fascial flaps,[12] and microsurgical intraneural neurolysis. Other techniques focus on removing causes of compression including removal of lipomas, fascial bands, bony spikes, etc. and even longitudinal plication of the brachioradialis tendon.[13]

Surgical decompression: To approach the superficial branch of the radial nerve, palpate the radial styloid process and follow the border of the brachioradialis proximal 10 cm. Draw a line connecting the two. Identify the area with the most pronounced Tinel response, tenderness, and allodynia. Then center your incision over this. Carefully elevate skin flaps to identify the brachioradialis and extensor carpi radialis longus tendons. The superficial branch of the radial nerve generally appears between the two tendons with brachioradialis located above and extensor carpi radialis longus located below.[12] Carefully dissect out the nerve and free it from adhesions. Remove any masses, adhesions, or fascial bands that could be compressing the nerve. Once fully decompressed, one can choose to wrap the nerve in a number of different adhesive barriers, including but not limited to amniotic membranes or fascial flaps. The area of nerve compression is carefully measured, and the adhesion barrier is trimmed to match. It is then placed around the nerve and secured loosely in place with 8-0 nylon sutures if needed. Attention is necessary for circumferential coverage without strangulation of the nerve. Upon achieving vascularity is confirmed, and hemostasis, one can proceed with layered closure and application of a soft sterile dressing.[12]

Postoperative care should consist of early range of motion at directed by physical therapy with all restrictions lifted by 2 weeks after surgery. Occupational therapy should reinforce this early range of motion protocol and incorporate nerve gliding techniques to minimize adhesion formation, desensitization, and scar massage. Patients generally receive 4 to 6 weeks of therapy and achieve maximum medical improvement at 60 to 90 days after surgery.

de Quervain's tenosynovitis[14][4]:

• Stenosing tenosynovitis in the first dorsal extensor compartment
• Pain, tenderness, and swelling over the lateral wrist
• No sensory disturbance
• Cheiralgia paresthetica itself gives a false positive Finkelstein test. Although, it may be associated with de Quervain tenosynovitis. Up to 50% of patients with cheiralgia paresthetica also get a diagnosis of de Quervain tenosynovitis

Lateral antebrachial cutaneous nerve neuritis:

• A lateral antebrachial cutaneous nerve provides sensation to the lateral forearm
• Positive Tinel test over the lateral antebrachial cutaneous nerve may be mistaken for positive Tinel test over the superficial branch of the radial nerve
• The superficial branch of the radial nerve and lateral antebrachial cutaneous nerve neuritis may coexist
• The sensory overlap between the superficial branch of the radial nerve and lateral antebrachial cutaneous nerve in the dorsoradial hand occurs in 21% to 75% of patients. Cadaveric dissections demonstrated the connection comes from the lateral branch of the superficial branch of the radial nerve.
• Check Tinel's test just distal to antecubital fossa just medial to the brachioradialis where the lateral antebrachial cutaneous nerve exits deep fascia
  • Tinel test may be positive in the course of the superficial branch of the radial nerve when there is a more proximal issue
• Must perform nerve block to lateral antebrachial cutaneous nerve before the superficial branch of the radial nerve to rule out a false-positive superficial branch of the radial nerve block if overlap exists

 Thumb carpometacarpal joint arthritis

• Pain at the in the radial aspect of the wrist
• Pain and weakness with motion, grip, and pinch 
• Crepitus with motion
• Positive Grind Test: pain with a circular motion of thumb while applying axial compression
• Possible adduction deformity of the thumb carpometacarpal joint alone or in combination with a hyperextension deformity of the thumb metacarpophalangeal joint (Z-type deformity)
• No sensory deficit

Proximal nerve lesion:

• Spinal cords lesions, nerve root compressions, brachial plexus injuries encompassing the posterior cords, radial nerve palsies, posterior interosseous nerve syndrome, and radial tunnel syndrome.
• Sensory disturbances will likely be associated with strength deficits. 

Intersection Syndrome

• Pain in the dorsoradial aspect of the forearm
• Crepitus over the intersection of abductor pollicis longus and extensor pollicis brevis with extensor carpi radialis longus and extensor carpi radialis brevis
• No sensory deficit

The outcomes for treatment of cheiralgia paresthetica are promising. It is very common for patients to have spontaneous resolution of their symptoms. There are reports of up to 71% of patients treated nonoperatively have good to excellent outcomes.[4] After nonoperative treatment fails, there are reports of mixed results for surgical management. Lanzetta and Foucher reported a 74% success rate with surgical intervention; while Calfee et al. report only modest results with 55% of patients treated operatively continued to symptoms at follow-up of 3.5 years.[4] Gaspar et al. also state several patients treated with simple nerve decompression do not have reliable results. Neurolysis for entrapment of the superficial branch of the radial nerve has greater recurrence rates and worse outcomes when compared to other peripheral nerve entrapment syndromes.[12]

Complications include but are not limited to unsuccessful surgical decompression, persistent symptoms, worsening of symptoms, iatrogenic nerve injury or injury to surrounding structures, and wound problems.

Cheiralgia paresthetica can be treated well with straightforward nonoperative interventions. The key to treatment is an accurate diagnosis and identification of the cause of the compression. Once the cause is determined, patients should be educated on techniques to remove the compression and to avoid activities that will aggravate the symptoms. These conservative measures will lead to symptom resolution in the majority of patients.

Cheiralgia paresthetica is a relatively common disorder that is underdiagnosed. The diagnosis is often confused with other wrist disorders. Successful management of cheiralgia paresthetica encompasses an interprofessional team approach. Clinicians, including the primary care provider and nurse practitioner who first see the patient, must be familiar with this disease and its presentation to diagnose it correctly. Having a high index of suspicion will lead to prompt diagnosis and initiation of treatment. Radiologists and neurologists can further verify the disease and identify the location of compression through imaging and electrodiagnostic tests.

Treatment initially consists of multifactoral conservative management with the removal of compression and avoidance of provocative activities. Brace therapy may be an initial approach with the input of orthotists. NSAIDs and other nerve medications may also be options; the pharmacist should verify appropriate agent selection, dosing, perform medication reconciliation, and counsel the patient regarding optimal NSAID use to avoid complications such as gastric upset, reporting any issues to the nurse or physician. If patients fail to improve with conservative management, a surgeon can remove anatomic nerve compression through a variety of techniques.  Postoperatively, the patient will benefit from physical therapy and occupational therapy focusing on early range of motion, nerve gliding exercises, and avoiding activities that exacerbate the condition. Specialty-trained nurses can monitor progress and provide patient education at follow-up visits and also watch for adverse medication effects, and let the treating physician know if there are any concerns. Open discussion and communication with the patient and between all of the health care providers on the interprofessional healthcare team is key to the successful treatment of this disease. [Level V]