Pronator teres syndrome is a

compression neuropathy Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a ''trapped nerve'', though this may also refer to ...

of the

median nerve The median nerve is a nerve in humans and other animals in the upper limb. It is one of the five main nerves originating from the brachial plexus. The median nerve originates from the lateral and medial cords of the brachial plexus, and has cont ...

at the elbow. It is rare compared to compression at the wrist (

carpal tunnel syndrome Carpal tunnel syndrome (CTS) is a nerve compression syndrome associated with the collected signs and symptoms of Pathophysiology of nerve entrapment#Compression, compression of the median nerve at the carpal tunnel in the wrist. Carpal tunn ...

) or isolated injury of the anterior interosseous branch of the median nerve ( anterior interosseous syndrome).

Symptoms

Compression Compression may refer to: Physical science *Compression (physics), size reduction due to forces *Compression member, a structural element such as a column *Compressibility, susceptibility to compression * Gas compression *Compression ratio, of a ...

of the median nerve in the region of the elbow or proximal part of the forearm can cause pain and/or numbness in the distribution of the distal median nerve, and weakness of the muscles innervated by the anterior interosseous nerve: the

flexor pollicis longus The flexor pollicis longus (; FPL, Latin ''flexor'', bender; ''pollicis'', of the thumb; ''longus'', long) is a muscle in the forearm and hand that flexes the thumb. It lies in the same plane as the flexor digitorum profundus. This muscle is uniq ...

("FPL"), the

flexor digitorum profundus The flexor digitorum profundus or flexor digitorum communis profundus is a muscle in the forearm of humans that flexes the fingers (also known as digits). It is considered an Muscles of the hand#Extrinsic, extrinsic hand muscle because it acts on ...

of the index finger ("FDP IF"), and the

pronator quadratus Pronator quadratus is a square-shaped muscle on the distal forearm that acts to pronate (turn so the palm faces downwards) the hand. Structure Its fibres run perpendicular to the direction of the arm, running from the most distal quarter of the ...

("PQ"). The pain tends to be at the wrist joint, in the distribution of the terminal branch of the anterior interosseous nerve, and is exacerbated by sustained pronation (i.e., wrist down). The weakness of the FPL and FDP IF is painless, but causes people to "drop things" and have a sense of loss of dexterity. Pinching with the wrist flexed magnifies the expression of this weakness, by reducing resting tension on the muscles of pinch. For instance, "child-proof" prescription pill bottles may be difficult to open. People easily adapt to this weakness without conscious effort or self-awareness, by using 1) the next muscles down, which are innervated by a different nerve, or 2) using ligaments to give resistance, pinching laterally against the index finger or against the side of the end of the thumb, or 3) by what is called "tenodesis," which in this case is extension of the wrist joint, which tightens the muscles on the palm side of the hand. These adaptations on a moment-to-moment basis do not cause problems, but over time in loose-jointed patients, such as many women and people with collagen disorders such as Ehlers Danlos Syndrome, the adaptations can cause

soft tissue Soft tissue connective tissue, connects and surrounds or supports internal organs and bones, and includes muscle, tendons, ligaments, Adipose tissue, fat, fibrous tissue, Lymphatic vessel, lymph and blood vessels, fasciae, and synovial membranes.� ...

failures that can become painful, particularly at the base of the thumb and in the proximal forearm (i.e., "Tennis Elbow" in a non-tennis player).

Causes

The most common cause is entrapment of the median nerve between the two heads of the pronator teres muscle. Other causes are compression of the nerve from the fibrous arch of the flexor superficialis, or the thickening of the

bicipital aponeurosis The bicipital aponeurosis (also known as lacertus fibrosus) is a broad aponeurosis of the biceps brachii, which is located in the cubital fossa of the elbow. It separates superficial from deep structures in much of the fossa. Structure The bici ...

.⁠

Anatomy

The median nerve passes through the

cubital fossa The cubital fossa, antecubital fossa, chelidon, inside of elbow, or, humorously, wagina, is the area on the anterior side of the upper part between the arm and forearm of a human or other hominid animals. It lies anteriorly to the elbow (antecubit ...

and passes between the two heads of

pronator teres The pronator teres is a muscle (located mainly in the forearm) that, along with the pronator quadratus, serves to pronate the forearm (turning it so that the palm faces posteriorly when from the anatomical position). It has two origins, at th ...

muscle into the forearm. It then runs between

flexor digitorum superficialis Flexor digitorum superficialis (''flexor digitorum sublimis'') or flexor digitorum communis sublimis is an extrinsic flexor muscle of the fingers at the proximal interphalangeal joints. It is in the anterior compartment of the forearm. It is s ...

and

muscles and enters the hand through the

carpal tunnel In the human body, the carpal tunnel or carpal canal is a flattened body cavity on the flexor ( palmar/volar) side of the wrist, bounded by the carpal bones and flexor retinaculum. It forms the passageway that transmits the median nerve and the ...

. It innervates most of the flexor muscles in the forearm and hand. Its sensory component supplies the skin of the palm, thumb, index and middle finger as well as half the ring finger, and, importantly and often forgotten, the bones of the wrist. In the proximal forearm it gives rise to the

anterior interosseous nerve The anterior interosseous nerve (volar interosseous nerve) is a branch of the median nerve that supplies the deep muscles on the anterior of the forearm, except the ulnar (medial) half of the flexor digitorum profundus. Its nerve roots come from C ...

which innervates the flexor of the thumb (FPL), the flexor digitorum profundus of the index finger (FDP IF), and the pronator quadratus, and terminates in a sensory branch to the bones of the wrist, i.e., the carpal tunnel. Compression of the proximal median nerve results in weakness of these three muscles, and can cause aching pain in the wrist on the basis of the sensory nerve to the

carpal bones The carpal bones are the eight small bones that make up the wrist (carpus) that connects the hand to the forearm. The terms "carpus" and "carpal" are derived from the Latin wikt:carpus#Latin, carpus and the Greek language, Greek wikt:καρπός ...

Diagnosis

The most common chief complaint is intermittent pain in the wrist, associated with sustained pronation, frequently misinterpreted by patients and providers as "tendonitis." This is usually accompanied by the perception of "hand weakness," and "dropping things." The characteristic physical finding is tenderness over the proximal median nerve, with ensuing numbness in the hand in less than a minute, and/or numbness in the hand with resisted pronation of the forearm in less than a minute. The flexor pollicis longus and FDP of the index finger are weak, leading to impairment of pinching firmly. This reflects involvement of the

. Sensory changes may be found in the first three fingers as well as in the palm, indicating impairment of the median nerve proximal to the flexor retinaculum, but tend to involve the sensation of the entire hand going numb at night, with any pressure on the median nerve on the areas at the inside of the elbow. The clinical and electrophysiological features of pronator teres syndrome are quite different from patients with

or pure anterior interosseous syndrome, and are typically normal. Proper localisation is crucial to treatment options.

Conduction velocity In neuroscience, nerve conduction velocity (CV) is the speed at which an electrochemical impulse propagates down a neural pathway. Conduction velocities are affected by a wide array of factors, which include age, sex, and various medical conditio ...

of the median nerve in the proximal forearm may be slow but the distal latency and sensory nerve

action potential An action potential (also known as a nerve impulse or "spike" when in a neuron) is a series of quick changes in voltage across a cell membrane. An action potential occurs when the membrane potential of a specific Cell (biology), cell rapidly ri ...

at the wrist are normal. Although

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

may show denervation atrophy of the affected muscles, its role in the evaluation of pronator teres syndrome is unclear.⁠ If the EMG or the MRI are abnormal for the pronator teres muscle and the flexor carpi radialis, this implies that the problem is at or proximal to the elbow, as the takeoff of the nerves to these muscles occurs proximal to the elbow.

Treatment

Injection of

corticosteroids Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invol ...

into the pronator teres muscle may produce relief of symptoms. Massage therapy can also provide relief for individuals experiencing this condition. Surgical nerve decompression can provide benefit in selected cases.Kalliainen LK, Ericson WB. "Management of Compressive Neuropathies of the Upper Extremity," Chapter 70, Grabb and Smith's Plastic Surgery, 8th Edition, Chung K et al, Editors. Lippincott Williams & Wilkins, 2018

References

External links

{{PNS diseases of the nervous system Peripheral nervous system disorders Syndromes