9
MEDIAN NERVE INJURIES
ABOUT THE ELBOW
BRIAN D. BURKE
KEITH MEISTER
Most injuries to the elbow in athletes are chronic overuse
injuries that are the result of repetitive intrinsic or extrinsic
overload. These injuries involve the soft tissues about the
elbow and occur with such frequency that many have collo-
quial names associated with them (1).
Compression nerve injuries about the elbow are far less
common but are becoming more prevalent as the number
of people participating in throwing and racquet sports in-
creases. Pronator syndrome has been recognized as a neural
compression syndrome within the proximal forearm and
elbow. It may be due to acute trauma (e.g., from a direct
blow) or from chronic, repetitive microtrauma (entrap-
ment). Women seem to be at greater risk than men, particu-
larly if they are exposed to highly repetitive, moderately
strenuous activities that require alternating pronation/supi-
nation motions (2). This mechanism is frequently encoun-
tered in overhead sports such as tennis, baseball, swimming,
and weight lifting. Affected athletes may complain of fa-
tigue-like pain with weakness and numbness in the forearm
and hand. Careful attention to the onset and location of
pain and weakness may help to decipher between exertional
compartment syndrome of the forearm, anterior interos-
seous syndrome, and true pronator syndrome. Neural
compression injuries are potentially serious and may delay
or preclude an athlete’s return to play unless properly diag-
nosed and treated. Essential to an accurate diagnosis is a
thorough history, precise physical examination, and knowl-
edge of the related anatomy. Diagnostic suspicion can be
confirmed by electrophysiologic testing. This is often help-
ful when a complex clinical presentation exists. Prevention
is the cornerstone of care. It combines education with the
use of proper equipment, technique, and conditioning to
provide the athlete with a mechanically stable and strong
extremity (3). When compression injury does occur, initial
treatment consists of rest, ice, compression, elevation, and
Department of Orthopaedic Surgery, Division of Sports Medicine, Univer-
sity of Florida, Gainesville, Florida 32607.
splinting along with the liberal use of antiinflammatory
medications. After an appropriate cool-down period, reha-
bilitation plays a critical role in reestablishing flexibility,
strength, and endurance. Surgery remains the definitive step
and may be necessary after nonoperative measures are ex-
hausted.
ANATOMY
The median nerve originates from the brachial plexus,
formed by contributions from the sixth through the eight
cervical roots and first thoracic nerve root (Fig. 9.1) (4).
Branches from the medial and lateral cords give rise to
the median nerve that courses through the upper arm adja-
cent to the brachial artery. At the anterior aspect of the
elbow, the median nerve, brachial artery, and biceps tendon
are oriented from medial to lateral (Fig. 9.2) (5). Typically,
the median nerve travels under the lacertus fibrosus, which
expands to coalesce with the antebrachial fascia covering
the superficial anterior forearm muscle group. It then pene-
trates the two heads of the pronator teres giving off branches
to this muscle as well as branches to the flexor carpi radialis
and palmaris longus (Fig. 9.3) (6). Considerable anatomic
variation can occur as the nerve traverses through the prona-
tor teres. The anterior interosseous nerve branches from the
median nerve at the distal margin of the pronator passage
and provides motor function to the flexor pollicis longus,
flexor digitorum profundus, and the pronator quadratus (7).
The main trunk of the median nerve continues under a
fibrous arch formed by the proximal border of the flexor
digitorum superficialis giving off intramuscular branches.
In the distal forearm, the palmar cutaneous branch arises
supplying skin over the thenar eminence. The median nerve
then enters the osseofibrous carpal tunnel to provide motor
and sensory function to the hand.
Entrapment of the median nerve about the elbow may
occur at various anatomic locations. As the median nerve
courses down the anteromedial aspect of the arm, it passes
beneath the ligament of Struthers and the lacertus fibrosus,
132 The Athlete’s Elbow

FIGURE 9.1. Schematic drawing of

the brachial plexus and its contribu-
tions to the median nerve.

FIGURE 9.2. Anterior forearm with orientation of the median FIGURE 9.3. Median nerve branches to the forearm muscula-
nerve as it courses by the elbow, through the forearm and distal ture.
to the carpal tunnel.
 9. Median Nerve Injuries 133

between the heads of the pronator teres, and under the

flexor digitorum superficialis arch. Compression at any of
these sites is collectively referred to as pronator syndrome
(8). Several accessory and variant muscles have also been
noted to cause median nerve compression syndrome in the
forearm. These would include the Gantzer muscle (acces-
sory head of the flexor pollicis longus), the palmaris profun-
dus, and the flexor carpi radialis brevis (9). Less commonly,
compressive lesions occur with a persistent median artery
or accessory bicipital aponeurosis (10).

EXAMINATION

The physical examination of the injured athlete’s elbow be-

gins with a thorough review of the injury mechanism and
any previous elbow pathology. Location and mechanism
provide essential clues, as sites and sources of elbow pain
are commonly categorized by anatomic compartments (1).
Individuals with median nerve entrapment often complain
of aching, radiating forearm pain that is localized to the
anterior compartment. The pain has an insidious onset and
may be associated with paresthesias and hypoesthesia of the
thumb, index, middle, and radial half of the ring finger.
They may also complain of weakness of the abductor pollicis
brevis and flexor pollicis longus muscles. Pains are exacer-
bated with repetitive forearm pronation and wrist flexion
while the elbow remains in extension. Continued activity
may cause the athlete to perceive weakness in the hand and
arm, forcing them to terminate play. Symptoms diminish
with rest and nocturnal exacerbation is uncommon.
Palpation reveals anterior compartment tenderness that
is usually localized over the proximal third of the pronator
teres. The pronator muscle may be firm, tender, and mildly
enlarged. Cramps and muscle spasms are found in some
cases and may be perceived as ‘‘writer’s cramps’’ in the stu-
dent athlete (11). The pronator compression test is a useful
and dependable physical sign. This test utilizes manual
compression of the median nerve at or near the pronator
teres. When positive, the patient reports recreation of symp-
toms with paresthesias and weakness in the extremity (12).
The Tinel percussion test is often positive about the prona-
tor teres but is noticeably absent from the carpal tunnel
region unless a double-crush phenomenon occurs. There is
no clinical weakness of the median nerve innervated intrin-
sic musculature unless the latter condition exists. To prevent
confusion between pronator syndrome and carpal tunnel
syndrome, several factors aid in distinguishing between the
two conditions (Fig. 9.4) (13). Infrequently, the two
compression neuropathies occur simultaneously or one may
antedate the other.
Three provocative tests have been described to help diag-
nosis and localize the site of median nerve entrapment in
pronator syndrome (1,7,9–13). One provocative maneuver
uses resisted pronation of the extended forearm to compress
FIGURE 9.4. Course of the anterior interosseous nerve as it
branches off the median nerve into the forearm.
the median nerve at the interval between the superficial and
deep heads of the pronator teres (Fig. 9.5) (14). Another
maneuver uses resisted elbow flexion and forearm supina-
tion to stress the nerve as it passes under the lacertus fibro-
sus. The third maneuver calls for resisted flexion of the
middle finger proximal interphalangeal joint while stabiliz-
ing the proximal metacarpal-phalangeal joint. This stresses
the flexor digitorum superficialis arch and suggests entrap-
ment at this location.
Diagnostic testing has a limited role in the work up of
this condition. The majority of cases are diagnosed clinically
after a thorough history and careful physical examination.
There are, however, unusual case presentations that may
prompt further investigation through specialty testing. Elec-
trodiagnostic studies including nerve conduction velocity
and needle electrode examination are infrequently used.
These tests may reveal neuronal abnormalities, but they are
rarely helpful in the acute setting (15). Furthermore, studies
have shown that only 10% of patients with pronator syn-
drome will have electromyographic findings that adequately
support the clinical diagnosis. Possible explanations for
these findings include the size and complexity of the median
nerve about the elbow. The nerve may be insufficiently
compressed to prevent a stimulus from progressing at a nor-
mal velocity through a significant number of fascicles. The
small number of fascicles that are affected have slowed im-
pulses that become blurred and dampened in the recording
(16). Newer techniques may improve the diagnostic acuity
134 The Athlete’s Elbow
FIGURE 9.5. Skin incision for release of the median nerve at the
elbow.
of electromyography, but at this time, pronator syndrome
remains largely a clinical diagnosis.
Sonography has been described and used clinically for
the detection of peripheral nerve lesions. High-resolution
sonography can visualize segments of nerve in the extremi-
ties and document abnormalities such as neuromas or ab-
normal inflammatory changes (17). Although this is a new
and interesting application of high-resolution ultrasound,
results are highly dependent on the experience and expertise
of the sonographer.
More expensive imaging modalities such as computer-
aided tomography and magnetic resonance imaging are
often unnecessary in the workup of routine pronator syn-
drome. They may, however, be beneficial in identifying a
suspected supracondyloid process or an accessory anatomic
structure.
NONOPERATIVE TREATMENT
Most sports-related compressive neuropathies are treated
conservatively with good results. One study reported more
than 50% of patients presenting with pronator syndrome
responded to nonoperative therapy (18).
In patients with symptoms of short duration, modifica-
tion or termination of activities that provoke the syndrome
should lead to its cessation. Those with refractory symptoms
or chronic injury may need a more thorough conservative
approach combining therapeutic modalities with the termi-
nation of offending activities. Studies have shown that treat-
ment programs combining several conservative modalities
generate a synergistic effect that leads to improved healing
and quicker recovery than programs utilizing a solitary mo-
dality (19). Immobilization provides protection of the elbow
while allowing the athlete to continue maintaining cardio-
vascular fitness. Typically, a removable splint is fashioned
with the elbow in flexion, the forearm in slight pronation,
and the wrist in slight flexion. This allows forearm muscula-
ture to relax in a favorable position relieving the suspected
anatomic compression of the median nerve. In the acute
setting, ice compresses and gentle massage are beneficial in
limiting inflammation and relaxing spastic muscles. Ionto-
phoresis and high-voltage galvanic electrical stimulation
have also proven to be successful in relieving pain and in-
flammation associated with pronator syndrome (20). Judi-
cious use of nonsteroidal antiinflammatory medications is
also initiated early in the treatment plan. Unlike the treat-
ment of carpal tunnel syndrome, steroid injections have
little to offer in the nonoperative treatment of proximal
median nerve compression (21).
Once the acute phase has passed, physical therapy is insti-
tuted. A rehabilitation protocol focusing on stretching,
strengthening, and an assessment of sport-specific technique
is often required. It is important for the athlete to recognize
that return to competition may be delayed 6 to 12 weeks
after initiation of the rehabilitation protocol. Once the ath-
lete regains pain-free full range of motion with protective
strength, sport-specific drills are begun. If the athlete toler-
ates progressive integration into game-type situations with-
out recurrence of symptoms, return to competition is al-
lowed.
The athlete must understand that surgery is not an al-
ternative to a dedicated and thorough trial of conservative
therapy. Documented failure of conservative therapy with
persistent symptoms, functional impairment, muscular at-
rophy, or progressive weakness is recognized as an indication
for surgical intervention.
OPERATIVE TREATMENT
Surgical release of the median nerve at the elbow begins with
an incision medial to the biceps border and approximately 5
cm proximal to the elbow crease. If an accessory bicipital
aponeurosis or supracondylar process has been identified,
the incision should begin at least 10 cm proximal to the
elbow crease (Fig. 9.6) (22). The incision tracks distal and
 9. Median Nerve Injuries 135

A B
FIGURE 9.6. A: Distal course of the nerve under the lacertus fibrosus. B: Median nerve coursing
deep to the flexor digitorum superficialis arch.

curves obliquely across the antecubital crease and then

gently curves medially for 5 cm in the proximal forearm.
Once through the skin, the medial antebrachial cutaneous
nerve is identified and gently retracted with the basilic vein.
The median nerve is then identified proximally along the
medial border of the brachialis. If a supracondylar process
or accessory bicipital aponeurosis has been identified preop-
eratively, the medial nerve must be identified and isolated
in the most proximal portion of the incision. The nerve is
then carefully traced distal and the ligament of Struthers is
excised (Fig. 9.7) (23). Careful exposure and exploration
of the entire nerve should be carried out as other sites of
compression about the elbow can coexist.
Dissection continues distal until the lacertus fibrosus is
encountered. It is carefully released and the nerve is then
followed to the proximal extent of the superficial (humeral)
head of the pronator teres. If an accessory bicipital aponeu-
rosis is present, it too is excised at this level. Retraction of FIGURE 9.7. Classic posture of the thumb during pinch with an-
the superficial head of the pronator will assist in recognizing terior interosseous nerve palsy.
136 The Athlete’s Elbow
any variation of the nerve’s course through the muscle. All
tendinous and fibrous bands within the pronator are identi-
fied then incised. If a median artery is found to penetrate
the median nerve, passage of the artery can be enlarged by
interfascicular dissection. Ligation of this artery is avoided
because it provides the dominant blood supply to median
nerve in 30% of cases and significantly contributes to the
blood supply of the index and middle fingers (10). If during
exposure a leash of muscular arterial branches from a median
artery is found crossing the nerve, these branches should be
ligated.
Most often, the median nerve passes directly between
the two heads of the pronator. The anterior interosseous
nerve can often be visualized branching from the median
nerve after retraction of the superficial head of the pronator.
If visualization is inadequate, the insertion of the superficial
head may be released and tagged for later reattachment (24).
Infrequently, both the anterior interosseous nerve and
the median nerve pass deep to the ulnar head of the pronator
teres. In this case, the deep head can be detached at its
tendinous insertion on the radius and reflected proximally
and ulnarly to fully expose the distal course of both nerves.
If further exposure is necessary, the radial origin of the flexor
digitorum superficialis can be released (24). Other anatomic
variations may be present, requiring careful dissection to
fully release and decompress the nerve.
Once through the pronator, attention is turned to the
flexor digitorum superficialis arcade. The anterior interos-
seous and median nerves pass deep to the superficialis arch.
This arch is incised because it may serve as a source of
compression, particularly if it is thickened. Dissection can
then be continued distal in search of accessory muscles or
other anatomic variations that may cause neural compres-
sion. Any site believed to be causing compression of the
nerve should be released.
The tourniquet is deflated and careful hemostasis is ob-
tained with bipolar electrocautery. If the superficial head
of the pronator required surgical release, reattachment is
performed. Care should be taken not to shorten or tighten
the muscle or a new compressive lesion may be created.
Epineurotomy or internal neurolysis of the median nerve
is not necessary and may be harmful. Subcutaneous transpo-
sition of the median nerve is also not recommended. The
wound is closed in layers without insertion of a drain. A
4-0 suture interrupted absorbable is used to close the subcu-
taneous layer and either a 5-0 nylon or 3-0 subcuticular
Prolene suture is used to close skin.
POSTOPERATIVE MANAGEMENT
A dry sterile dressing is applied and the elbow is placed
in a well-padded immobilization device with care taken to
position the wrist in slight flexion while the elbow is placed
at 90 degrees of flexion and 45 degrees of pronation. If
nylon sutures were used to close the skin, these are removed
5 to 7 days after surgery. Plastic adhesive strips are then
applied across the wound and allowed to stay in place for
another week. Care must be taken not to remove sutures
too quickly, as this incision has a tendency to spread open
resulting in a poor cosmetic result. Once the incision has
healed, gentle massage about the scar is encouraged. This
will result in softening of periincisional scar formation.
Immobilization is discontinued within the first week,
allowing for initiation of gentle range-of-motion exercises.
Stretching and isometric strengthening are continued until
the patient regains full, pain-free range of motion. Resis-
tance strength training is delayed until 6 to 8 weeks after
surgery. Sport-specific drills are integrated into the rehabili-
tation regimen after protective strength is achieved. Full
return of function may take 6 months or longer, often elimi-
nating an athlete from a season of competition.
COMPLICATIONS
As with any surgical procedure, complications may arise.
Strict adherence to sterile technique along with the generous
soft tissue coverage encountered in this procedure have led
to little problem with skin flap necrosis, infection, or wound
breakdown. Preoperative antibiotics offer additional pro-
phylaxis against infection and are a standing order at our
institution
Hypertrophic scar formation has been reported with
some frequency and is believed to result from excessive skin
tension during closure or premature removal of skin sutures.
Neurologic injury is minimized with identification and
careful dissection about the nerve. Dissection along the me-
dian nerve should always start proximal and progress distal.
A thorough knowledge of upper extremity anatomy with
possible anatomic variations is essential. Retraction on neu-
rovascular structures should be gentle and performed only
with vessel loops. Interfascicular dissection along the me-
dian nerve is to be avoided unless a persistent median artery
traverses the nerve (10). Persistent or recurrent nerve
compression after thorough surgical release is rare. Restora-
tion of functional strength and motion often requires effort
but has not posed a problem during rehabilitation.
ANTERIOR INTEROSSEOUS SYNDROME
Isolated anterior interosseous nerve palsy is reported to ac-
count for less than 1% of all upper extremity peripheral
neuropathies (25). This syndrome was first described in
1918 by Tinel and later elaborated on by Kiloh and Nevin
(26).
A deep unremitting pain in the proximal forearm usually
precedes the symptoms that ultimately define anterior inter-
osseous syndrome. Patients may note a lack of dexterity or

weakness of pinch that fails to resolve. Clinical findings
include a loss of function of the flexor pollicis longus and
flexor digitorum profundus to the index and middle fingers
with weakness of the pronator quadratus. Sensibility is unaf-
fected and tenderness over the proximal forearm is usually
absent. It may present as an incomplete syndrome with
either weakness or absence of the flexor pollicis longus and
flexor digitorum profundus to the index and middle fingers
with normal pronator quadratus function. This is prognos-
tically significant, as studies have shown that outcome after
surgery is better for complete than for partial lesions of this
nerve (27).
Flexing both elbows at 90 degrees and resisting forearm
pronation tests the pronator quadratus. This effectively re-
duces the strength contribution of the pronator teres hu-
meral head, allowing for more accurate comparison of pro-
nator quadratus function and therefore a more accurate
assessment of a complete versus incomplete lesion.
The thumb and index finger assume a classic position
during pinch in this syndrome (22). The index finger ex-
tends at the distal interphalangeal joint with compensatory
increased flexion at the posterior interphalangeal joint. The
thumb hyperextends at the interphalangeal joint and dis-
plays increased flexion at the metacarpophalangeal joint.
During the initial period of observation, electrodiagnos-
tic studies should be obtained. Time is permitted for wal-
lerian degeneration to be detected electromyographically
and this is usually seen within 3 weeks after the onset of
symptoms. Conservative measures used in treating anterior
interosseous nerve syndrome mirror those used for pronator
syndrome. If there is no sign of clinical or electromyographic
improvement in 2 to 3 months, surgical exploration is indi-
cated. Even though return of function has been documented
up to 18 months after the onset of symptoms, expectant
treatment has been less predictable that surgical intervention
and recovery is often incomplete (27,28).
OPERATIVE TECHNIQUE AND
POSTOPERATIVE MANAGEMENT
The surgical approach and extent of median nerve explora-
tion, as well as postoperative management, is the same
whether the diagnosis is anterior interosseous compression
or pronator syndrome with one caveat. Careful interfascicu-
lar neurolysis, assisted by using an operating room micro-
scope, is warranted in patients with anterior interosseous
syndrome when an obvious compression site cannot be
identified at surgery. A report by Nagano et al. (29) found
that eight of nine patients with anterior interosseous syn-
drome had an hourglass-like fascicular constriction of the
anterior interosseous nerve within the median nerve 2.0 to
7.5 cm above the elbow. They postulated that inflammation
of the nerve results in edema, which causes the fascicles to
9. Median Nerve Injuries 137
adhere. Recovery after interfascicular neurolysis was good
and other authors have confirmed this finding (30).
The most frequent cause of entrapment in anterior inter-
osseous nerve syndrome is fibrous bands in the pronator
teres muscle. The usual finding is constriction about the
ulnar head of the pronator teres as it crosses the posterolat-
eral aspect of the anterior interosseous nerve, shortly after
it branches from the median nerve. The fibrous reaction is
probably associated with the acute episode of pain, suggest-
ing a localized vascular reaction such as thrombosis or is-
chemia. Results after surgical decompression of anterior in-
terosseous nerve syndrome are very good, as one study
reported 32 of 34 patients treated operatively regained full
function (31).
COMPARTMENT SYNDROME OF THE
FOREARM
When associated with fracture, crush, or burn injury, com-
partment syndrome of the forearm is a well-recognized en-
tity (32–34). Exertional compartment syndrome of the
forearm, however, is relatively uncommon. Symptoms
begin after a relatively short period of exertion and persist
as long as the rigorous activity continues. Numbness and
tingling often herald the onset of elevated compartment
pressures. The distribution of symptoms varies depending
on the compartment(s) involved. Weakness and painful mo-
tion followed by inability to continue the offending activity
should lead one to include compartment syndrome in their
differential diagnosis. Cessation of the offending activity
often results in marked improvement of symptoms over a
period of 20 to 30 minutes (33).
Pain with passive motion is the most reliable physical
finding. However, compartment pressure measurement is
the only truly reliable method of diagnosis (34). A physician
must have a high index of suspicion to obtain intramuscular
pressure readings and these readings are often obtained only
after the development of chronic exertional compartment
syndrome. The key feature in differentiating compartment
syndrome from other compressive neuropathies is the ability
to obtain a quantitative difference in forearm compartment
readings between preexercise and postexercise activities.
Care must be taken to measure and document accurate read-
ings for the volar (anterior or flexor), the dorsal (posterior
or extensor), and mobile wad compartments. Once a diag-
nosis is made, decompression fasciotomies of all involved
compartments is indicated.
References
1. Safran MR. Elbow injuries in athletes. Clin Orthop 1995;310:
257–277.
2. Morrey BF. Nontraumatic conditions of the elbow. In: Morrey