Pronator Teres Syndrome - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the condition of Pronator Teres Syndrome.
Which nerve is involved with the pronator teres syndrome?
Median nerve.
Pronator teres syndrome is compression of the median nerve at the level of the elbow which occurs more in women.
In the forearm, the median nerve runs between the two heads of the pronatoer teres muscle and then lies between the flexor digitorum superficialis and flexor digitoum profundus muscles.
Pronator teres syndrome could be associated with medial epicondylitis.
The principle symptoms of numbness in the radial 3 1/5 fingers as well as thenar weakness may be mistakenly attributed to carpal tunnel syndrome.
Potential sites for intrapment of the nerve includes:
. Most common cause is due to compression of the median nerve between the two heads of the pronator teres muscle.
. It occurs in people who preform repetitive forceful pronation of the forearm.
. Compression due to thickening of the bicipital aponeurosis, the aponeurosis crosses from the lateral to medial over the antecubital fossa and may irritate the median nerve.
. Compression of the nerve from the fibrous arch of the origin of the flexor digitarum superficialis (FDS).
The median nerve runs dowen the medial side of the arm and passes 2 ½ to 4 cm below the level of the medial epicondyle before it enters between the two heads of the pronator teres.
About 1% of patients have a medial supracondylar humeral spur about 5 cm proximally to the medial epicondyle.
The ligament of struthers is attached to this bony projection which connects the process to the medial epicondyle.
The bony process points towards the elbow joint.
The median nerve can become compressed by the supracondylar spur.
The median nerve can also become trapped by the ligament of struthers that extends from the supracondylar process to the medial epicondyle.
The ligament of struthers is different from the arcade of struthers, which deals with compression of ulnar nerve around the elbow.
Clinical presentation:
Paresthesia in the lateral 3 ½ fingers may occur with compression of median nerve at the elbow region or at the carpal tunnel region.
Symptoms are similar to the carpal tunnel syndrome but are worst with rotation of the forearm.
Patient will complain of dull aching pain over the proximal forearm with no night time symptoms.
The pain is usually worsened by repetitive or forceful pronation.
Tenderness of palpation to the pronator teres muscle.
The median nerve gives off a palmar cutaneous branch before entering the carpal tunnel.
Sensory disturbances over the palm of the hand occur due to involvement of the palmar cutaneous branch of the medial nerve and this occurs proximal to the carpal tunnel.
This differentiates between the carpal tunnel syndrome and the pronator teres syndrome.
Examination Tests:
There are specific provocative tests that produce the pain and distal paresthesia are used to localize the site of compression.
Tinel’s sign at the wrist will be negative.
Phalen’s test will be negative.
Median nerve compression tests are negative at the carpal tunnel; however there will be a positive Tine’s sign at the proximal forearm.
When compression of the nerve involves the supracondylar process, the test is considered positive if symptoms of tingling worsen while tapping on the spur.
Occasionally the spur can be felt.
The pronator teres muscle can be assessed as the cause of the median nerve compression in different ways.
Resisted forearm pronation with elbow flexion will test for compression at the two heads of the pronator teres muscle.
The patient’s forearm is held in resisted pronation and flexion.
While remaining in a pronated position the forearm is gradually extended.
Compression of the median nerve can also be tested by:
- Resisted elbow flexion with forearm supination (compression at the bicipital aponeurosis).
- Resisted contraction of the FDS to the middle finger (compression at the FDS arch).
Differential Diagnosis:
- C6/C7 Radiculopathy; involvement of the nerves at these levels will cause numbness of the thumb, index and long fingers, as well as weakness of the muscles of the forearm that are innervated by the median nerve.
The radial nerve part of C6- C7 will show normal function of the wrist extensors and the triceps.
- Carpal Tunnel Syndrome.
X-rays, imaging and nerve conduction studies may be helpful in the diagnosis.
Treatment:
. Rest.
. Splint.
. NSAIDs.
Surgical decompression of the median nerve through all 4 or 5 possible sites of compression when non-operative management fails for 3-6 month.
The results of surgery are variable, full recovery is not always seen in all patients.
About 80% of the patients improve with surgery.
The skin incision may leave an unsatisfactory scar.

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