Diagnosis

History: The individual may report a diffuse, aching pain in the forearm with a feeling of clumsiness or fatigue
after prolonged activity. The pain often radiates down the forearm towards the wrist. Occasionally the symptoms
may move up from the elbow towards the shoulder. There may be instances of numbness (paresthesia) in the
thumb and index finger, and the individual may report loss of dexterity in the hand. Symptoms are typically worse
with activity, especially forceful gripping or twisting movements; symptoms generally improve with rest. Unlike
median nerve compression at the carpal tunnel, nighttime symptoms are less commonly reported.

Physical exam: The characteristic physical finding is tenderness over the proximal median nerve. The
symptoms are often increased with resisted pronation of the forearm (Hartz).

Sometimes the involved forearm may appear thicker (hypertrophied) than the uninvolved side. Like CTS,
compression of the median nerve from pronator syndrome may result in pain or paresthesia at the thenar
muscles of the thumb (Disabella). There may be tenderness on the flexor surface of the forearm in response to
the examiner touching (palpating) the point where the median nerve enters the pronator teres muscle near the
elbow. The pronator compression test is a valuable clinical feature (Gainor).

Muscle testing may reveal weakness in the forearm and hand intrinsic muscles supplied by the median nerve
(e.g., forearm pronators, wrist flexors, and finger flexors). Pinch strength may be diminished, and there may be
weakness with resisted middle finger flexion. Resisted forearm pronation, during which the elbow is extended
and the wrist flexed (pronator syndrome test), may reproduce painful symptoms. Resisting elbow flexion at 120°
to 130° while the forearm is facing downward (in a position of maximal supination) also may reproduce
symptoms. Tapping of the median nerve at the elbow may elicit pain and tingling (Tinel sign); conversely, tapping
of the median nerve at the wrist will not elicit symptoms. A complete neurological examination should be
performed to rule out spinal sources of neuropathy.

Because of the similarity to other syndromes (CTS, AIN), diagnosis can be difficult.

Tests: Laboratory blood tests (complete blood count [CBC], uric acid, erythrocyte sedimentation rate [ESR], and
antinuclear antibody [ANA] testing) are typically not useful in establishing this diagnosis. Electromyography
(EMG) and nerve conduction velocity (NCV) testing may be performed to help confirm the physical exam
diagnosis and rule out other locations of median nerve entrapment (e.g., CTS, cervical radiculopathy, thoracic
outlet syndrome); however, NCV testing is not always diagnostic.

False negative and positive NCV test results are common for this condition. The traditional median nerve motor
conduction test records the response from the abductor pollicis muscle in the palm. This muscle is affected by
CTS. Median nerve motor conduction test results showing slow conduction of the median nerve in the forearm,
conduction block at the wrist of the fastest axons, and reduced amplitude of the motor response in the palm in
response to median nerve stimulation at the elbow most commonly represent moderate or severe CTS, and not
pronator syndrome. Needle EMG evidence of denervation in forearm muscles innervated by the median nerve
should be observed before pronator syndrome is diagnosed.

X-rays and magnetic resonance imaging (MRI) also may be performed to rule out bony or soft tissue causes of
nerve compression.
Source: Medical Disability Advisor

Treatment
Proper localization is crucial to treatment options. Pronator syndrome cases associated with heavy
arm use are initially treated with protection, rest, ice, compression, elevation, medication, and
modalities (PRICEMM). During the acute phase of this condition, the individual should modify
activities to avoid movements and forces that increase symptoms. The individual also may benefit
from temporary use of a brace or splint to allow the limb to rest; severe cases may require activity
modification and splinting for up to 6 months (Kim; Santiago). Nonsteroidal anti-inflammatory drugs
(NSAIDs) may be tried during this phase, although in general, they do not affect nerve entrapment
syndromes. Physical therapy may be helpful to loosen tight musculature and restore strength to the
affected limb.

Local injection of an anesthetic agent (median nerve block) or corticosteroids about the median nerve
at the elbow may be necessary to provide symptom relief. If symptoms persist and the appropriate
diagnosis is made (the correct location of the median nerve entrapment is identified), surgery is
usually successful.

Occasionally, when the diagnosis is difficult tricyclic antidepressants may be prescribed, particularly if
sleep is disturbed. Anticonvulsant medications may be indicated for neuropathic pain. Unfortunately,
these treatments mask the symptoms and do not treat the cause.

Source: Medical Disability Advisor

Prognosis
The outcome of pronator syndrome is excellent. Approximately 50% of individuals with pronator
syndrome receiving conservative treatment experience resolution of symptoms within 4 months (Lee).
Up to 90% of those who undergo median nerve decompression surgery report good to excellent
results (Lee).

Source: Medical Disability Advisor

Rehabilitation
The focus of rehabilitation for pronator syndrome is to restore full use of the elbow, wrist, and hand
with a painless forearm. The first goal of therapy is to identify the sources of strain and to modify
activities to avoid repetitive movements and overuse of the affected extremity. Individuals are advised
to avoid forceful gripping or repeated pronation and supination activities. Ice may be used to reduce
pain, and the individual may be instructed to perform ice massage on the affected forearm. The
therapist may instruct the individual to protect the affected extremity by using an immobilization splint.
Other modalities, including ultrasound, electrical stimulation, phonophoresis, and iontophoresis, may
be useful to decrease pain, control swelling, and facilitate stretching exercises of tight forearm
 musculature (Santiago).

After the acute phase, stretching of tight forearm muscles (e.g., pronator teres, forearm flexors) may
be facilitated by the application of heat before stretching. Soft tissue mobilization of tight structures
may also be helpful. Once painful symptoms are reduced, strengthening exercises may be initiated
for the hand, wrist, and elbow, at first isometrically and then against gentle resistance within pain-free
ranges of motion, progressing as indicated. It is important to protect against further injury during this
time, especially through either too little or too much activity. As strength returns, the individual may
begin conditioning exercises with progression to full activity. An ergonomic assessment of the
individual's workplace may be needed to evaluate proper biomechanics with task performance to help
reduce the risk of re-injury.

A home program should be taught to complement supervised rehabilitation, and should be continued
after the completion of physical therapy.
FREQUENCY OF REHABILITATION VISITS
Nonsurgical
Specialist Pronator Syndrome
Physical or Occupational Up to 4 visits within 6 weeks
Therapist with home exercise program

Surgical
Specialist Pronator Syndrome
Physical or Occupational Up to 6 visits within 8 weeks
Therapist with home exercise program

Source: Medical Disability Advisor

Complications
Unresolved pronator syndrome may result in chronic weakness, pain, and impaired functional use of
the hand and wrist. Permanent median nerve damage may result.

Source: Medical Disability Advisor

Ability to Work (Return to Work Considerations)

The extent of injury, associated motor and sensory deficits, and type of work will dictate the type of
work restrictions or accommodations necessary. Individuals may need to temporarily immobilize the
affected extremity to allow healing to fully occur.

The literature is limited for specific risk, capacity, and tolerance for pronator syndrome. The factors for
CTS are similar and are listed here until additional evidence-based medicine studies become
available.
 For more information refer to "Work Ability and Return to Work," pages 1–8; 196–201.

Risk: The risk for recurrent median nerve entrapment is low (Szabo).

Capacity: Most activities can be safety performed in the pre- and postoperative period. Limiting forceful grip,
along with tolerance, is the key during the early phases. If surgery was performed wound healing requires
protecting the surgical incision site from contact with chemicals and water immersion. Gradual return to heavy
activities is appropriate (Talmage).

Tolerance: Tolerance for symptoms is dependent on rewards. Self-employed individuals often return to regular
activities as tolerated; that is the reason why employed individuals may have various lengths of disability.
Outcomes for individuals receiving workers’ compensation are poorer than for others (Adams).

Accommodations: The key to limiting unnecessary disability is communication with the individual as to what
he or she can do at work instead of what he or she cannot do. Similarly, employers should stress the benefits to
the individual for staying at work or returning to work early.

Source: Medical Disability Advisor

Maximum Medical Improvement

30 days, non-surgical.

60 days, surgical.

Source: Medical Disability Advisor

Regarding diagnosis

Regarding diagnosis:

 Does individual have a history of repetitive task-type injury to the upper extremity in which repeated or
forceful gripping or twisting occurs?
 Did individual have complaints of diffuse, aching pain and a feeling of clumsiness and fatigue in the
forearm with activity?
 Were there instances of paresthesia in the thumb and index finger? Loss of hand dexterity?
 Did individual’s symptoms typically worsen with activity, especially forceful gripping or twisting movements,
and improve with rest?
 Was there an absence of nighttime symptoms?
 Do individual’s forearm flexor muscles appear thickened (hypertrophied)?
  Did individual experience tenderness at the flexor surface of the forearm in response to the examiner
touching (palpating) the muscles near the elbow?
 Did individual exhibit weakness in the forearm and hand intrinsic muscles supplied by the median nerve
(e.g., forearm pronators, wrist flexors, and finger flexors)?
 Did resisted forearm pronation (pronator syndrome test) reproduce symptoms?
 Did tapping of the median nerve at the elbow elicit pain and tingling (Tinel sign)?
 Was EMG and NCV testing used properly to confirm the diagnosis?
 Were x-rays needed? MRI?
 Did workup include a complete neurological examination?

Regarding treatment:

 Was diagnosis of pronator syndrome confirmed by needle EMG?

 Was individual treated with protection, rest, ice, compression, elevation, medication, and modalities
(PRICEMM)? Was this helpful?
 Is individual modifying activities to avoid movements and forces that bring on symptoms?
 Is individual using temporary brace or splint to allow the injured limb to rest?
 Are NSAIDs indicated? Are tricyclic antidepressants or anticonvulsant medications necessary?
 Is individual receiving physical therapy? Is individual compliant in performing home exercise program as
instructed?
 Was individual’s work environment assessed to facilitate proper biomechanics with task performance? Is
ergonomic setup correct?
 Has individual received median nerve block or injection of corticosteroids into the median nerve? Did this
resolve symptoms?
 Is surgery necessary to release the tight structures from about the median nerve (median nerve
decompression surgery)?

Regarding prognosis:

 Were modifications made to the individual’s job requirements during recovery?

 Was the dominant or nondominant arm affected?
 Has physical therapy been completed as recommended? Would additional therapy benefit individual?
 Did adequate time elapse for full recovery?
 Was individual able to eliminate the cause of the original injury?
 Did permanent median nerve damage result?

Source: Medical Disability Advisor

References

Cited
Adams, M. L. , et al. "Outcome of carpal tunnel surgery in Washington state workers'
compensation." American Journal of Industrial Medicine 25 (1994): 527-536.
Chumbley, Eric M., Francis G. O'Connor, and Robert P. Nirschi. "Evaluation of Overuse Elbow Injuries." American
Family Physician 61 3 (2000): 691-700.

Damert, Hans Georg, et al. "Minimally Invasive Endoscopic Decompression for Anterior Interosseous Nerve
Syndrome." Journal of Hand Surgery 38A (2013): 2016-2024.

Disabella, Vincent N. "Elbow and Forearm Overuse Injuries." eMedicine. Eds. Sherwin SW Ho, et al. 14 Jun. 2013.
Medscape. 1 Nov. 2014 <http://emedicine.medscape.com/article/96638-overview>.

Gainor, B. J. "The Pronator Compression Test Revisited. A Forgotten Physical Sign." Orthopaedic Review 19 10
(1990): 888-892.

Hartz, C. R., et al. "The Pronator Teres Syndrome: Compressive Neuropathy of the Median Nerve." Journal of Bone
and Joint Surgery (American volume) 63 6 (1981): 885-890.

Kim, Richard Y., Valerie M. Wolfe, and Melvin Rosenwasser. "Section I – Entrapment Neuropathies Around the
Elbow." DeLee and Drez’s Orthopaedic Sports Medicine. Eds. Jesse C. DeLee, David Drez, and Mark D. Miller. 3rd
ed. Saunders Elsevier, 2009.

Lee, Michael J., and Paul C. LaStayo. "Compressions that Mimic Carpal Tunnel Syndrome." Journal of Orthopadedic
Sports Physical Therapy 34 1 (2004): 601-609.

Melhorn, J. M. "Unnecessary Disability - Why Can't I Work?" Impairment without Disability. Ed. W. G. Buchta. Mayo
Clinic, 2011.

Mercier, Lonnie R. "Pronator Syndrome." Ferri's Clinical Advisor 2010. Ed. Fred Ferri. Mosby Elsevier, 2010.

Santiago, Francisco H., and Ramon Vallarino. "Chapter 20: Median Neuropathy." Essentials of Physical Medicine and
Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier,
2008.

Szabo, R. M. , et al. "Carpal Tunnel Syndrome as a Work-related Disorder." Repetitive Motion Disorders of the Upper
Extremity. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1995. 421-434.

Talmage, J. B., J. M. Melhorn, and M. H. Hyman. "Why Staying At Work or Returning To Work Is In The Patient's
Best Interest." The Guides to the Evaluation of Work Ability and Return to Work. Eds. J. B. Talmage, J. M. Melhorn,
and M. H. Hyman. American Medical Association, 2011. 1-8.

Waldman, Steven D., ed. "Chapter 66: Entrapment Neuropathies of the Elbow and Forearm." Pain Management. 1st
ed. Saunders Elsevier, 2006.

General
Tsai, Peter, and David Steinberg. "Median and Radial Nerve Compression About the Elbow." Journal of
Bone and Joint Surgery 90 (2008): 420-428.