In an adult right‑handed patient with a 2‑year history of forearm pain that worsens during fine‑motor activities (typing, mouse use, handwriting), occasional radiation to the elbow, shoulder, or wrist, normal nerve‑conduction studies, unremarkable MRI of the forearm and elbow, and a negative compartment pressure test, what are the likely etiologies and is a forearm fasciotomy a reasonable treatment option?

Likely Diagnosis and Treatment Recommendation

Your presentation is most consistent with radial tunnel syndrome or a non-specific work-related upper limb disorder (WRULD), and a fasciotomy is NOT indicated given your negative compartment pressure testing and lack of evidence for compartment syndrome.

Most Probable Diagnoses

Radial Tunnel Syndrome (Primary Consideration)

• Radial tunnel syndrome presents with lateral elbow and dorsal forearm pain that radiates to the wrist and dorsum of fingers, precisely matching your symptom distribution 1
• The condition is diagnosed primarily through clinical examination rather than electrodiagnostic testing or imaging, which explains why your nerve conduction studies and MRIs were normal 1
• It occurs from intermittent compression of the radial nerve between the radial head and inferior border of the supinator muscle, most commonly at the arcade of Frohse 1
• MRI may show muscle edema or atrophy along the posterior interosseous nerve distribution, though this is not always present 1
• The condition is more prevalent in women aged 30-50 years and occurs without obvious extensor muscle weakness 1

Work-Related Upper Limb Disorder (Secondary Consideration)

• Intensive mouse use (>30 hours/week) and keyboard use (>15 hours/week) are established risk factors for forearm pain, directly correlating with your symptom onset after prolonged computer use 2
• Your symptom pattern—pain triggered specifically by fine motor computer tasks but not by cooking or gym activities—is characteristic of computer-related forearm disorders 3, 2
• Limited epidemiological evidence supports a causal relationship between computer mouse time and forearm disorders, as well as wrist tendonitis 3
• The seven-day prevalence of moderate-to-severe forearm pain in computer workers is 4.3%, with one-year incidence of 1.3% 2

Contributing Factors

• Your unidentified back issue causing positional pain may contribute through cervical radiculopathy or thoracic outlet syndrome, potentially explaining the radiation pattern to your neck during the initial acute episode 4
• High job demands and time pressure are independent risk factors for onset of forearm pain, with women having twofold increased risk 2

Why Fasciotomy Is NOT Appropriate

A fasciotomy should absolutely not be performed in your case for the following definitive reasons:

• Fasciotomy is indicated for compartment syndrome, which you explicitly do not have based on negative compartment pressure testing 2
• The procedure carries surgical risks including nerve damage, infection, scarring, and potential worsening of symptoms without addressing the underlying nerve compression or overuse pathology
• Your clinical picture shows no evidence of the acute ischemia, tense compartments, or elevated pressures that would justify this invasive procedure
• The occurrence of clinical disorders requiring surgical intervention in computer-related forearm pain is low, suggesting computer use is not commonly associated with severe occupational hazards requiring fasciotomy 2

Recommended Management Algorithm

First-Line Conservative Management (Despite Previous Failures)

• For radial tunnel syndrome, non-surgical treatments including rest, NSAIDs, injections, and physiotherapy may not provide permanent relief but are justified before considering surgery 1
• Modify your workstation ergonomics: reduce mouse time to <30 hours/week and keyboard time to <15 hours/week through voice dictation software, ergonomic input devices, and frequent breaks 2
• Consider a trial of corticosteroid injection at the point of maximal tenderness (likely the arcade of Frohse region) under ultrasound guidance

Diagnostic Refinement

• Request specific clinical examination for radial tunnel syndrome including the "rule of nine" test and assessment of third finger and wrist extension weakness 1
• Consider repeat MRI specifically looking for muscle edema or atrophy along the posterior interosseous nerve distribution 1
• Evaluate for cervical radiculopathy given your concurrent neck/back issues and the initial radiation to your neck 4

Surgical Consideration (Only After Exhaustive Conservative Management)

• If conservative management fails after 6-12 months, surgical decompression of the radial tunnel can diminish pain and symptoms in 67-93% of patients 1
• This would involve release of the radial nerve at compression sites (arcade of Frohse, radial recurrent vessels, fibrous bands), NOT a fasciotomy
• Surgery should only be considered after confirming the diagnosis through positive response to diagnostic nerve blocks

Critical Pitfalls to Avoid

• Do not proceed with fasciotomy without documented compartment syndrome—this is the wrong operation for the wrong diagnosis
• Do not dismiss the diagnosis simply because electrodiagnostic studies are normal; radial tunnel syndrome is a clinical diagnosis 1
• Do not ignore the occupational component; symptom management requires both medical treatment and workplace modification 2
• Consider that your back issue may be contributing through referred pain or nerve root compression, requiring concurrent evaluation 4