PRONATOR TERES SYNDROME

A. Definition
Pronator teres syndrome is a set of typical symptoms characterized by mild to
moderate pain in the forearm. Pain increases with movement of the elbow, supination and
pronation repetitive and repetitive movements grip. The loss of manual dexterity, mild
weaknesses, paresthesia median nerve can occur, numbness can occur not only on the finger,
but can also occur in the area because terkenanya palms palmar cutaneous nerve area that
branched.

B. Epidemyology
Pronator teres syndrome is the second most common cause of median nerve
compression behind carpal tunnel syndrome. It tends to occur in athletics (especially
those with rapid, exertional supination and pronation) and in occupations where the
forearm may be hypertrophied. In addition, anomalies involving the ligament of
Struthers and the course of the median nerve may contribute to median nerve
entrapment.

C. Etiology
The most common cause is entrapment of the median nerve between the two
caput pronator teres muscle. Other causes compression of the nerve from the fibrous
arch of the superficial flexor, or thickening of the bicipital aponeurosis
There are five areas of potential occurrence of neural Bondage
1. Supracondylar Process
 Found only approximately 1%

2. Ligament of Struthers
Under the ligament of Struthers, the network that runs from processus
suprakondiler the distal humerus (ulnar side) to the medial epicondyle.
At the elbow that is on its way along the pronator teres muscle, so that
there are three places on the passage of nerve compression that can
occur, which is a branch of the biceps tendon and the ulnar insersio
pronator teres muscle.
In the carpal tunnel in the wrist.

3. Bicipital aponeurosis
4. Among the ulnar and humerus Caput on pronator teres
5. Aponeurosis arch FDS
D. Clinical Manifestation
The median nerve compression at the elbow: pronator Teres syndrome
Is a mixture of sensory-motor mononeuropathy.
Pain in the forearm that is worsened by the attitude of pronation and forced
flexion.
Tingling in the area of the median nerve.
Pain in the area pronator teres muscle stimulation or Tinel's sign.
The existence of mild weakness in the forearm and thenar muscles, or it could
be no weakness.
The median nerve along with the artery separates the biceps tendon and fascia
of the biceps. Then continues between two insersio of the pronator teres
muscle (on the medial epicondyle and coronoid process of the ulna). In this
area median nerve is localized under the ulnar artery and the fascia of the
biceps tendon. There are more underneath Origin of the flexor digitorum
superficialis muscle.

E. Clinical Symptoms
Local symptoms were obtained:
Heaviness, stiffness or cramping of the hands.
Tingling sensation in the muscles of the thenar thumb and three fingers on his
side.
Pain in the area pronator teres muscle in the elbow or forearm when muscles
contract.
Pain and tingling while doing antagonistic movements like pronation of the
forearm and flexion of the wrist.
Motor dysfunction of the muscles innervated by the median nerve distal to the
collateral (after leaving the pronator teres muscle innervation); so the pronator
 teres muscle dysfunction, but could not hit the muscle pronator quadrates
affected.
Baal and thicker on the medial side of the thumb and the lateral side of the
index finger.

Arthralgia on elbow
The median nerve plays a major role in the region of the elbow, which
berkolateral the anterior capsule of the ligament apparatus parts. If after
fraktus or dislocated elbow, certain movements still cause pain, then the
management of the median nerve must be considered.

Signs and Symptoms of Sensorik

Pain is the main symptom of SPT. Discomfort felt at the onset of forearm
pronation due to pinched nerves and flexion is often done with a powerful,
usually the initial diagnostic manual. Obtained also the onset of acute pain due
to severe contraction of the forearm. This pain radiates from the region distal
to the anterior elbow to the palms and fingers, also proximally to the shoulder.
Tingling in the thumb and other fingers are innervated normally accompanies
the median nerve pain. But without a test activation / pronator provocation,
sometimes not found. Pain along the proximal portion of the pronator teres
muscle is an important diagnostic sign of the syndrome.

Signs and Symptoms of Motorik

At SPT, worsening of symptoms and sensory mototik not go together.
There is a discrepancy between the motor and sensory symptoms. Of the many
findings of sensory symptoms, only 3 of 39 cases there is also a motor
symptoms (mild thenar muscle atrophy). Just got a little weakness of the
flexor pollicis and Opponens pollicis, although there is pain and sensory
deficits on the distribution of the median nerve innervation. In theory, in the
case of median nerve compression in the tax return where there are severe
sensory deficits, will obtain minimal weakness (at least) on some of the
muscles supplied by the median nerve, such as radial nerve entrapment
syndrome and ulnar. However this is not found in SPT, and the reason remains
 unclear.

F. Diagnosis
Diagnosing SPT is not easy because the signs and symptoms overlap with
compression and entrapment neuropathy of the median nerve, among others: Struthers
ligament compression at the top, carpal tunnel syndrome (CTS) below, and the
anterior interosseous nerve lesions in anatomical locations almost the same as the
SPT. Muskulofibrosa tissue from the base of the pronator teres muscle, is one of the
findings of pathological compression during the operation of the SPT, which is also
the main cause of the anterior interosseous nerve syndrome in some cases. When The
median nerve enters the forearm area, then the significant anatomical variations
certainly aka tone. These variations together with minor anatomical variations at the
point where the anterior interosseous nerve departs from the median nerve, is the
beginning of an explanation why fibrous connective tissue of the pronator teres
muscle or flexor digitorum superficialis Akif role in the pathogenesis of SPT and
anterior interosseous nerve syndrome. Both clamping nerve syndrome had similarities
to the discovery of visible pathology during surgery, which is associated with clinical
signs and symptoms including pain and tenderness over the forearm. Although the
anterior interosseous nerve is purely motor, but the onset paralisisnya generally
associated with acute pain and in the forearm, as well as the pain felt over the
pronator teres muscle in some cases. The weakness of the flexor pollicis longus and
flexor digitorum profundus of the index finger, which is a major physical sign of the
anterior interosseous nerve syndrome (AIS), seen at SPT. Clinically, the only criteria
that differentiate between SPT and the anterior interosseous syndrome is a sensory
signs are distributed along the median nerve of the forearm. When there is clearly a
sensory deficits, the diagnosis can be confirmed is the SPT. If the patient has only a
subjective ambiguity regarding sensory symptoms without definite tingling in the
median nerve area, after tests pronator and flexor digitorum superficialis test, then it is
very difficult to ascertain whether a tax return or AIS case with consideration of
sensory symptoms. Anatomically, the presence of one or more muscle paralysis
proximal to the base of the anterior interosseous nerve, can support the diagnosis of
SPT. Pronator teres muscle, the flexor carpi radialis, palmar longus, and pleksor
digitorum superficial, should be examined specifically and carefully at SPT and SIA.
 In accordance neuroanatomy, signs and symptoms of median nerve lesion at
the level of Struthers ligament and pronator teres muscle is almost identical. The
difference is the location of tenderness, muscle responsible namely suprakondilar
muscle and pronator teres muscle, and there is a spur at suprakondylar on radiographs.
Struthers ligament compression syndrome known to be extremely rare, but should still
be included in the list of differential diagnosis of paralysis of the median nerve, as it is
clamping nerve neuropathy can disembuhkan.

G. Physical Examination
Provocative tests specifically on Examination bondage Median Nerve
The patient stands with the elbow flexed 90 degrees. The examiner places one
hand on the patient's elbow stabilization, and the other hand grasping the hands
of Pasian in a position to shake hands. Patients maintain this position, while
inspectors perform supination of the forearm of patients (forcing patients to
contract the pronator muscle patients). While doing supination movements,
inspectors also carry out extension at the elbow, with a grip to pull the distal.
If there is pain or discomfort at the moment, it is ascertained that there is
compression of the median nerve by the pronator teres. (The patient should
remain merelaksikan elbow during the test, because of the stiff elbow will be
difficult for the examiner at the time of the extension).

H. Therapy
Management conservatively be applied before considering surgical
intervention. The main goal of treatment is decompression of the median nerve.
Consideration or treatment is effective in relaxing the pronator and flexor muscles, as
well as reducing the mechanical stress on the system fibromuskuler of the forearm.
SPT found in the group of people who work or habit is predominantly excessive use
of the forearm. Thus, it is important to educate the patient is the first step that must be
done in the management of this syndrome.
1. Intervention Non surgery
Conservative management is almost always a top choice early in the
operation, and often obtain positive results. With conservative therapy,
50% of patients reported relief in 4 months. Others reported that the repair
can be found in the 18 months up to 2.5 years after conservative therapy.
Cortisone injection is done when conservative therapy has not succeeded
in improving the symptoms. The decision to choose surgery / surgical
determined within 8 weeks forevermore 6 months after conservative
management. The median nerve decompression generally have a 85-90%
possibility to get good results.
Management of the types of jobs and hobbies: multiply rest and
adjustments to the activities, if possible, modified total.
Drugs and dosing neurorehabilitasi exercises to loosen the tension
fibromuscular and to reduce pain.
Exercise actively and dynamically in the upper limb into
consideration long-term effects when the pain has diminished or
disappeared.

Conservative rehabilitation
Phase 1: Week I-II
Aim:
Controlling swelling
The reduction of pain

Intervention:
Protects the elbow of entrapmen further with the use of
splinting or fixation elbow 900.
Activities passive ROM carefully.
Elevation, cooling and compression.
Modalities and medications for inflammation, swelling
and pain.
Massage gently nerve.
Mobilization of soft tissue.
Maintenance of the condition and stamina.
 Phase 2: Week III-IV
Aim:
Improved flexibility
Strengthening (in this phase takes extra care to prevent
recurrence)
Intervention:
The modalities can help to reduce inflammation and
pain.
Exercise wrist flexion and extension should be done.
After the above exercise can be done well, then
continued with elbow flexion and extension and
pronation and supination slowly.
Mobilization and massage the soft tissue in the forearm
can begin in areas where there is a suspicion of
entrapmen.
Start solve this type of exercise and activity, with the
development of the condition and stamina.

Phase 3: Week V-VIII

Aim :
Independently are able to perform the program at home
To return to activity in work, recreation, and sport
Prevention of recurrence
Intervention:
Education to patients about prevention and management.
Massaging and sorting nerve to prevent recurrence.
For an athlete, strengthening and flexibility are essential
components for exercising again.
Focus on repeated simulations both in sports and work of
the patient

2. Surgery
Exploration and decompression of the median nerve to be done if
the failure of conservative management. Decompression is done with the
anterior approach and a longitudinal incision along the arm. The incision
will start a few centimeters above the supracondylar processus (Struthers
ligament), if the decompression is also needed in the area. However, the
incision can also be made just above the elbow bump up to the middle of
the forearm. Identification very carefully from nerve entrapment area
should really be confident that the surgery only area that it only needs to
be opened for the decompressed. SPT diagnosis must be perfectly upright
before carrying out the operation.

Postoperative rehabilitation
Phase 1: Valid I-XXI
Aim:
Controlling edema and pain
Preventing infection at the wound site
Start trying ROM is active in around the joint
Reduce the sensitivity of the area of the incision scar tissue
and improve mobility

Intervention:
Protection of the scar area and monitor drainage.
Rest, cooling, and elevation of the arm.
The elbow is positioned slightly flexed (fixation) for 7-10
days.
Active movement of the fingers, wrists, and shoulders
(hereinafter, including the elbow and forearm).
Nerve mobilization exercises are gentle and pain free.
Iontophoresis and modalities needed to reduce inflammation
and pain.
Mobilization of soft tissue and gently massage to reduce
swelling on network maintenance.

Phase 2: Week IV-VII

Aim:
The power grip and elbow reaches about 30-50% of the
healthy hand
Increased active ROM of the forearm and elbow by more
than 50% of normal
Advanced Prevention of adhesions and scar tissue
sensitivity
Independent ADL
 Ensuring appropriate ergonomic exertion (work and leisure)

Intervention:
Passive Stretch on elbow, forearm, wrist, and shoulder.
Patient education regarding the prevention of recurrence.
Exercises that are balanced to the elbows, wrists, forearms,
and shoulders.
Start a training simulation for both work and leisure

Phase 3: Week VI-XII

Aim:
The strength adequate to restore the activity and work in full
Independent management of the symptoms

Intervention:
Simulation of work activities and sports.
Progress upper extremity exercises that make up the
resilience to return to work and sports activities. Stretching
exercises and a continuation of phase 1 and 2 in accordance
with the indications.
 Reference

1. Soeroso, Joewono. 2015. Ilmu Penyakit Dalam 6th edition Jilid III. Jakarta : interna
publishing. Page 3552.
2. Disability Guidelines Al-Shatoury AHA. Pronator teres syndrome. [Internet]. 2012. [Updated
21th September 2012, cited 1stjuly 2014]. Available from :
http://www.mdguidelines.com/pronator-syndrome
3. Salawati , Liza dan Syahrul. 2014. Carpal tunnel syndrome. the medical journal of the
university medical faculties Syiah kuala. Vol 14 No 1.