DR G AVINASH RAO

FELLOW HAND AND

MICROSURGERY
SKIMS

MODERATOR
PROF DR ADIL H WANI

PRONATOR
SYNDROME
 Journal club – JHS DEC 2020

CURRENT CONCEPTS – PRONATOR

SYNDROME

 Jeremy A. Adler, MD, Jennifer Moriatis Wolf, MD, PhD. Proximal

Median Nerve Compression: Pronator Syndrome J Hand Surg Am.
2020;45(12):1157e1165.
ANATOMY OF THE MEDIAN NERVE IN THE
FOREARM

 The median nerve receives contributions from C5 to C8 and part of T1

at the level of the brachial plexus.
 Nerve roots C5 to C7 combine to form the lateral cord, and C8 and T1
combine to form the smaller medial cord.
 These cords coalesce to become the median nerve, which crosses the
brachial artery from lateral to medial at the midarm, continuing
distally between the biceps and brachialis.
Anatomy
 As the median nerve enters the antecubital fossa, it lies deep to the
lacertus fibrosus (LF), a fibrous structure originating from the ulnar
border of the biceps brachii.
 The nerve then most commonly travels between the 2 heads of
pronator teres (PT).
 Distal to the PT, the nerve descends deep to the 2 heads of the flexor
digitorum superficialis (FDS) and continues distally into the forearm
between the flexor digitorum profundus (FDP) and FDS.
 Enters carpal tunnel at wrist lying deep to PL and ulnar to FCR.
 PATHOLOGIC SITES OF MEDIAN NERVE COMPRESSION

 The most common sites of proximal median nerve compression from

proximal to distal are
 the lacertus fibrosis,
 the 2 heads of PT, and
 the fibrous arch of FDS,
 although other sites of compression have been noted.
 The presence of one constricting structure does not rule out the
possibility of an additional site of compression at a separate anatomic
location.
 Pronator teres
 The PT most commonly has both humeral (superficial) and ulnar
(deep) heads, but the deep head can be absent in up to 45% of people
and may be replaced by a distinct fibrous structure.
 The humeral head originates from the medial intermuscular septum of
the arm and a supracondylar ridge of the medial epicondyle, and the
deep head originates from the coronoid process ulnarly.
 In 19% of cadaveric forearms, Dellon and Mackinnon found the origin
of the superficial head to be at least 2 cm proximal to the medial
epicondyle. When this variant was present, the fascia, which often
coalesces with the lacertus, was in a position to compress the median
nerve.
 The 2 heads converge to run diagonally, coalescing to form the
common pronator tendon, inserting more distally on the lateral aspect
of the radius.
 The median nerve travels between the 2 heads in approximately 74%
to 95% of the population, but can also travel deep to both heads or
pierce either head.
 Constricting bands within the pronator muscle itself may also be
present when the nerve penetrates the superficial head, which was
reported in 78% of patients treated surgically by Werner et al.
 Overdevelopment or hypertrophy of the flexor-pronator mass, which
is constricted by the surrounding antebrachial fascia and the LF, can
also compress the nerve.
 There is no consensus in the literature as to which pathologic variant
is most commonly found during surgery.
 Mujadzic et al found a fibrous arch of the deep head to be most
common, whereas Johnson et al most frequently encountered a fibrous
band over the dorsum of the superficial head.
 Lacertus fibrosus (bicipital
aponeurosis)
 The LF is a fascial extension from the ulnar aspect of the distal biceps
tendon that courses obliquely across the antecubital fossa and
coalesces with the deep fascia of the overlying flexor musculature.
 It can be a site of compression as it travels anterior to the median
nerve, especially when there is a high origin of the humeral head of
the PT.
 Hartz et al reported that during surgery, the lacertus compressed the
pronator during passive pronation as the tendon of the biceps moved
distally and drew the lacertus with it.
 Flexor digitorum superficialis fibrous arch

 The FDS most commonly has humeroulnar and radial heads. The
humeroulnar head originates from the medial epicondyle and either
the interosseous membrane or the most radial surface of the ulna.
 The radial origin is much wider and arises obliquely from the volar
radius. One or both heads of the FDS can form tendinous or fibrous
aponeurotic arches under which the median nerve travels before
continuing distally into the forearm.
 The arch lies approximately 6.5 cm distal to the humeral epicondylar
line and 1 to 2 cm distal to the deep head of the PT.
 Multiple case series noted that the PT was the most common site of
compression of the proximal median nerve. The proportions of
patients with identified pathologic compression at these structures
were
 33% to 76% for PT,
 0% to 42% for lacertus,
 14% to 36% for FDS.
 Ligament of Struthers/supracondylar process

 The ligament of Struthers is a fibrous structure that extends from the

distal medial humeral diaphysis to the medial epicondyle.
 It is present in approximately 1% to 2% of the population and can
extend from an anteromedial bony projection of the humeral
diaphysis, called a supracondylar process.
 The process can form an accessory origin of the PT, which can also be
implicated as a site of compression.
 The ligament of Struthers can be found without a supracondylar
process, often occurs bilaterally if present and can compress the
median nerve approximately 5cm proximal to the medial epicondyle.
 Whereas the presence of this structure is rare, median nerve
compression by the ligament is considered even less common.
 Gantzer muscle

 An accessory head of the flexor pollicis longus (FPL), or Gantzer

muscle, is present in 20% to 75% of limbs and can arise from the
medial epicondyle, coronoid process, and/or interosseous membrane
between FDS and FDP.
 Caetano et al noted that the anomalous muscle always lies dorsal to
both the median nerve and anterior interosseous nerve (AIN), which
was consistent with previous studies.
 In contrast, Mangini reported that the accessory head always lies
between the median nerve volarly and the AIN dorsally.
 Other sites of proximal median nerve compression have been
reported, including a

1. vascular arcade crossing the nerve at the level of the PT,

2. an exostosis of the radius,

3. a fibrous component of the FCR originating from the ulna, and

4. adherent fascial bands on the anterior surface of the brachialis.

 Presentation
 Patients with pronator syndrome (PS) commonly describe a vague
aching pain in the proximal forearm, paresthesias in the median nerve
distribution, and pain with activity.
 Symptoms usually have an insidious onset without a precipitating
event and present around the fourth and fifth decades of life.
 This diagnosis is more commonly reported in women, with no
evidence supporting a relationship with hand dominance.
 Activities that require persistent elbow flexion and forearm
supination, forearm pronation, and repetitive grasping can place the
pronator and lacertus on stretch, compressing the median nerve and
thus reproducing symptoms.
 Patients may describe decreased grip or pinch strength, or generalized
weakness as well as loss of fine motor skills.
 Patients sometimes report paresthesias or numbness in the volar radial
three and a half fingers and the thenar eminence.
 Acute PS can occur as a result of sports activities and weight lifting
and is more likely to occur in the younger, more active patient
population.

 They present with an acute muscle sprain or episode that precipitates a

PS.
 Physical examination
 Patients with PS present with tenderness in the proximal forearm with
palpation.
 The distal radial edge of the PT can be palpated around 6 cm distal to
the elbow crease and 4 cm lateral to the medial epicondyle in adults.
 An indentation of the flexorpronator mass below the medial
epicondyle may suggest the lacertus fibrosis as a source of
compression.
 Motor strength in all of the median/AIN innervated muscles,
particularly the FPL, FDP, and flexor carpi radialis, should be
evaluated individually and compared with the contralateral extremity.
 Hagert et al noted objective weakness in FCR and FPL in all 82
patients with PS in their surgical case series.
 A Tinel sign can be present in the proximal forearm at the level of
maximal tenderness, although multiple studies reported a positive
result in less than 50% of patients.
 Tinel, Phalen, and carpal tunnel compression tests should be
performed at the wrist.
 Pronator compression test
 The pronator compression test is performed by applying pressure over
the PT in the trajectory of the median nerve. It is one of the most
common examination findings reported in surgically treated patients.
 A test is positive when this provokes paresthesias after 30 seconds of
sustained pressure.
 Provocative maneuvers
 The pronator muscle can be dynamically tested by having the patient
pronate the forearm against resistance with the elbow in 0 to 45 of
flexion.
 With the elbow in 100 to 135 of flexion, paresthesias with resisted
elbow flexion and forearm supination suggest the LF as a source of
compression.
 The FDS can be tested by asking the patient to flex the middle finger
proximal inter phalangeal joint against resistance.
 However, this test may also be positive in CTS, because contraction of
the FDS may draw the lumbrical muscle bellies into the carpal tunnel
and cause median nerve compression distally.
 Differential diagnoses
 Alternative diagnoses to consider include CTS, AIN syndrome,
thoracic outlet syndrome, brachial neuritis, and cervical radiculopathy.
 Carpal tunnel syndrome is the most commonly reported misdiagnosis
for patients with PS.
 Hagert and Olehnik et al found 49% of the cohorts in their study had
undergone previous unsuccessful carpal tunnel decompression before
presentation.
 Although CTS and PS have similarities, several key distinguishing
factors can help the clinician arrive at the correct diagnosis.
 Patients with PS may have numbness in the thenar eminence, which is
often absent in CTS given that the palmar cutaneous branch of the
median nerve originates proximal to the wrist crease and does not pass
through the carpal tunnel.
 Tinel, Phalen, and carpal tunnel compression tests at the wrist are
often negative in isolated PS.
 Aching pain in PS is localized to the proximal forearm and worsened
with provocative maneuvers.
 Some authors have suggested that muscle fatigue and proximal Motor
weakness (infrequently) is more common in PS, whereas thenar
atrophy Positive electrodiagnostic studies (more common) is more
indicative of CTS.
 Improvement after corticosteroid injection (CSI) in the forearm also
provides both diagnostic and therapeutic information.
 It is possible to have CTS and PS simultaneously.
 The AIN branch of the median nerve can also be compressed in
similar locations causing an AIN syndrome (AINS). Because the AIN
is a purely motor nerve, patients should present only with muscle
weakness unless a concomitant CTS is suspected.
 EMG studies, which are often negative in PS, may confirm the
diagnosis of AINS in 80% to 90% of patients.
 Workup
 X-rays are rarely diagnostic in PS.
 Radiographs of the elbow may demonstrate a supracondylar process.
 Minimal literature exists regarding the diagnostic utility of magnetic
resonance imaging or ultrasound in PS.
 Magnetic resonance imaging can be helpful if there is concern for
extrinsic causes of compression such as a tumor or hematoma.
 Although ultrasound has not been described for the evaluation of PS,
authors have imaged the median nerve in AINS and showed multiple
stenotic lesions with hourglass-like constrictions of the AIN.
 Because of the lack of current clinical evidence, ultrasound and
magnetic resonance imaging are not routinely recommended in the
workup of PS.
 Electrodiagnostic studies
 Electromyographic and nerve conduction studies are often negative or
inconclusive in cases of PS.
 In a review of 4,838 EMG studies performed on patients with a
possible upper-extremity neuropathy, only 2/1,000 were found to have
electrodiagnostic study (EDS) findings of PS. Electrodiagnostic study
results may be positive in only 7% to 31% of patients treated
surgically.
 If Nerve conduction studies (NCS) are positive, they may show
decreased conduction velocities from the elbow to the wrist.
 EMG can be used to identify conduction abnormalities of median
nerve-innervated muscles and occasionally demonstrate denervation
of the PT.
 Lack of evidence of individual muscle denervation does not rule out
proximal median nerve compression, because the magnitude of nerve
fibers involved may not be enough to produce detectable changes.
 Literature Consenses
 Some researchers have theorized that PS is a dynamic ischemic
neuropathy, with intermittent compression with multiple sites
involved.
 In a study using dynamic EDS with comparison of nerve conduction
in healthy volunteers and PS patients, no differences before and after
exercise were noted between groups.
 In contrast, Werner et al reported that 3 patients in their surgical
cohort had reduced amplitudes after isometric pronation before
surgery, and after surgery the change was no longer detectable.
 Literature Consenses
 McCue et al suggested a higher likelihood of improvement after
surgery when EDS were positive.
 Others noted no difference in outcomes between PS patients with
normal versus positive EMGs.
 Although some authors reported abnormal EDS findings more
consistently than others, most of the evidence shows that these studies
are often inconclusive and far less commonly positive than that seen
in other compressive neuropathies.
 EMG or nerve conduction velocity is used primarily to rule out other
possible causes of peripheral nerve compression, particularly in
patients with distal sensory symptoms.
 TREATMENT - Conservative management

 All patients with a diagnosis of PS should initially be managed with

nonsurgical treatment, because improvement has been reported in
29% to 70% of patients.
 Although there are limited data supporting a specific duration or
regimen of nonsurgical treatment, most clinicians begin with a trial of
at least 3 to 6 months of some combination of Rest and nonsteroidal
anti-inflammatory drugs, Pronator Stretchings, activity modification,
physical therapy, and CSIs.
 Patients should avoid activities that involve repetitive elbow flexion,
forearm pronation, and forceful gripping, because these maneuvers can
exacerbate symptoms.
 Some authors recommend immobilizing the elbow in flexion for 2
weeks, but allow orthosis removal for gentle range of motion exercises.
 Corticosteroid injections may provide symptomatic relief and also
diagnostic information.
 Morris and Peters found that a combination of CSI into the PT muscle
and activity modification resulted in improvement in 5 of 7 patients.
 Seyfarth reported that all 17 patients in their cohort improved after
injection of local anesthetic.
 No long-term studies have determined the duration of relief or
proportion of patients with complete resolution of symptoms after
CSI.
 Surgical treatment
 Surgery should be considered in patients with a diagnosis of PS who
have failed nonsurgical treatment and whose symptoms are persistent
and debilitating.
 Multiple surgical incisions at the proximal forearm have been
described, including a lazy S, oblique, or transverse volar incision.
 Regardless of the type of incision, the goal of surgery is to release all
suspected compressive structures to decompress the median nerve
adequately.
 Earlier studies recommended evaluation and decompression at all
possible compressive sites, because it is difficult to predict the
location of compression reliably before surgery.
 Exploration of the median nerve proximally to decompress a possible
ligament of Struthers should be tailored to the surgeon’s concerns
before surgery.
 More recent series by Hagert and Zancolli et al demonstrated success
with a more limited decompression at only 1 or 2 of the most common
sites of compression.
 Seitz et al reported 100% improvement in a cohort of 7 patients
treated by release of the LF alone; however, all patients in that group a
partial traumatic biceps tendon tear.
 Newer endoscopic and miniinvasive techniques have also been
described and reported outcomes similar to those of previous studies.
 If a patient has clinical signs of both CTS and PS, simultaneous
decompression can be performed with satisfactory outcomes.
 OUTCOMES - Literature
Consenses
 Surgery in PS has been associated with improvement in symptoms in
71% to 93% of patients, often noticeable within the first 6 weeks after
surgery.
 All of the current literature regarding surgical intervention is
composed of retrospective case series, and there is notable variability
in the outcome measures that are used.
 Johnson et al reported that 47 of 51 had complete resolution of
sensory symptoms and most examination findings were no longer
detectable by the time of suture removal.
 OUTCOMES - Literature
Consenses
 The 4 failures were attributed to either recurrent scarring or
misdiagnosis.
 Hartz et al reported that of 36 surgically treated patients, the results
were excellent in 8 forearms, good in 20, and fair in 5. Three patients
had no improvement. A good result meant that most symptoms were
relieved and the patient could pursue all previously limited activities
despite the presence of mild nondisabling weakness, pain, and/or
paresthesias. Patients with a fair result were able to work part-time but
had residual episodes of disability.
 OUTCOMES - Literature
Consenses
 Olehnik et al reported similar outcomes in 39 patients, with complete
relief in 26%, partial relief in 51%, and no improvement in 9%. Of 39
patients, 19 had undergone a CTR before presentation, and there was
no significant difference in outcomes between the previously treated
subgroup and the 20 patients who had not undergone a prior surgery
(P > .05). Eight of 12 patients with an abnormal nerve conduction
velocity before surgery improved with surgery, whereas 20 of 25 with
a normal nerve conduction study improved. No significant difference
was found between these subgroups (P >.05).
 OUTCOMES - Literature
Consenses
 Hagert and Hagert reported on pronator release in 82 forearms (73
patients) performed through a transverse incision with decompression
of only the PT and LF.
 Of the 82 forearms, 62 had complete pain relief with restoration of
strength and sensation, whereas 22% had improved strength but
persistent elbow pain (15 patients) or paresthesias (3 patients). Only 2
patients had no improvement.
 OUTCOMES - Literature
Consenses
 Werner et al used a similar limited decompression and reported
complete or partial relief in 89% of patients.
 Lee et al endoscopically decompressed 14 forearms in 13 patients
with PS. All patients were offered a more traditional open approach,
but all elected for endoscopic treatment.
 The authors used a 3-cm longitudinal incision and pathology was
assessed at the 3 most common sites of compression.
 OUTCOMES - Literature
Consenses
 In 64% of patients had complete resolution of symptoms and 36% had
partial relief with mostly mild occasional symptoms. The authors
noted an average of 90% improvement in Disabilities of the Arm,
Shoulder, and Hand scores after surgery.
 Zancolli et al published results of a mini-invasive approach performed
on 44 patients with simultaneous carpal tunnel and proximal median
nerve decompressions.
 OUTCOMES - Literature
Consenses
 Zancolli et al. noted that in almost all cases, the only compressive
structure was the deep fascia of the superficial head of the PT muscle,
and therefore an extensive decompression was not required. They
reported that 93% of patients had complete resolution of symptoms
and 7% had no improvement. Of the 3 failures, 2 had preoperative
complex CTS with permanent numbness. The other patient had
resolution of nighttime symptoms, but owing to persistent daytime
symptoms and pain with pronation activities, a revision proximal
decompression was performed and the patient recovered completely.
 OUTCOMES - Literature
Consenses
 Good results of simultaneous proximal and distal median nerve
decompression have been shown.
 El-Haj et al reported results for 27 patients, 23 with both diagnoses
and only 4 with isolated PS. Of 13 patients who had previously
undergone a CTR, 7 had a revision decompression at the wrist. They
reported a 93% success rate by comparing preoperative with
postoperative visual analog scale pain scores, Disabilities of the Arm,
Shoulder, and Hand scores, and grip and pinch strength.
 OUTCOMES - Literature
Consenses
 Hsiao et al retrospectively reviewed a series of 21 patients with
diagnoses of PS and CTS who were treated with simultaneous
decompression. The authors reported that 71% of patients had
complete relief of pain and paresthesias, had no sensory deficits, and
had grip and pinch strength improvement greater than 85% compared
with the contralateral hand. Six of 21 patients had occasional
paresthesias and pain without sensory deficit, but with less than 50%
pinch and grip strength compared with the contralateral side. All 6 of
these patients had an unsuccessful CTR before the simultaneous
revision CTR and proximal median nerve decompression.
 OUTCOMES - Literature
Consenses
 Most authors report minimal complications associated with surgery.
 Lee et al reported 3 transient complications in that surgical case series
of 13 patients. These included an AIN palsy that resolved at 4 weeks,
a hematoma that resolved at 3 weeks, and an allergic reaction to an
adhesive dressing with no long-term sequelae.
 OUTCOMES - Literature
Consenses
 Authors have reported improvement in 76% to 93% of patients with
limited decompression at the PT and/or lacertus, whereas 71% to 92%
of patients improved with more extensive decompression.
 This suggests that limited decompression may address most nerve
compression, but comparative studies are needed to prove this. It is
not clear why some patients do not improve with surgery, although
some authors report that patients with severe primary CTS or those
who failed previous carpal tunnel surgery may have higher rates of
failure.
 Need for studies in the future
 Most current outcomes data are based on retrospective case series
with variable outcome measures by surgeons describing their own
physical examination and surgical techniques. Because of this, some
dispute the validity of the diagnosis itself and argue that PS is an
illness construct, not a disease.
 Until reliable objective pathophysiology is defined and stringent
prospective studies are performed, the diagnosis and treatment options
for PS will likely remain controversial.
 Comparing surgical versus nonsurgical management can aid the
development of an optimal intervention protocol and assess the
efficacy of the various understudied nonsurgical treatments. There is
considerable variability among authors with regard to both the type of
incision and the actual structures that are decompressed.
 Pronator syndrome should be considered in the differential for all
patients with proximal forearm pain and median nerve paresthesias.
 Because the diagnosis relies on the clinical presentation and
examination, the pronator compression test and other provocative
maneuvers are valuable tools to supplement the physical examination.
 If surgical treatment for suspected CTS is unsuccessful, PS should be
considered.
 Electrodiagnostic studies are often negative, and no reliable evidence
exists supporting an improved prognosis in patients with positive
findings..
 If patients fail nonsurgical management, evidence demonstrates that
surgical intervention can provide satisfactory outcomes. The type of
surgical technique should be tailored to the provider’s comfort level,
and all suspected sites of compression should be evaluated and
adequately decompressed. Before surgery, patients should be
counseled that although most patients improve, surgery may not
completely resolve symptoms