Elbow ConditionsPronator Teres syndromeSupinator syndromeUlnar sulcus syndrome SEE LEAF and WALTHER MANUALSFOR IN DEPTH DISCUSSIONZatkin/Stark 2007

Zatkin/Stark 2007

Pronator Teres SyndromeEntrapment of Median nerve between ulnar and radial heads of Pronator Teres musclemost common site of compression caused by muscle hypertrophy or thickening of aponeurotic fascia between two heads of pronator teresMedian nerve enters forearm passing between the two heads of pronator teres and then deep to flexor digitorum superficialis arch, continuing between flexor digitorum superficialis and flexor digitorum profundus in forearmZatkin/Stark 2007*

Zatkin/Stark 2007

Pronator Teres SyndromeThere are four reported sites of median nerve compressionpronator teres: most commonflexor digitorum superficialis arch: second most common, fibrosis of flexor digitorum superficialis arch supracondylar process/ligament of struthers lacertus fibrosis (bicipital aponeurosis) *

Lacertus FibrosisThe lacertus fibrosis, an aponeurotic expansion, originates at the musculotendinous junction of biceps brachii medially and blends distally with fascia of superficial flexor mass and inserts on proximal ulna*

Pronator Teres SyndromeSymptoms of decreased hand strength, problems with writing, numbness/tingling in hand and especially palm, pain in proximal forearm, fatigue with exerciseSigns and symptoms usually worse with activityNocturnal symptoms seen with carpal tunnel syndrome are typically absentNegative Phalen's test Weakness of median innervated muscles may only appear after provocative tests (resisted pronation)

Weakness of finger flexors (ie: flexor digitorum profundus) Strengthens with approximation of proximal radius and ulnaZatkin/Stark 2007*

Zatkin/Stark 2007

Pronator Teres Syndrome

Weakness of finger flexors (ie: flexor digitorum profundus) Strengthens with approximation of proximal radius and ulnaZatkin/Stark 2007*

Zatkin/Stark 2007

Pronator Teres SyndromeChallenge radial head and adjust Often superior or lateral

Test Pronator teres for proper function Weakness Shortened : SCS/RSCS, FF, etcTest for core muscle dysfunctionEsp transverse abdominisZatkin/Stark 2007*

Zatkin/Stark 2007

Median Nerve Provocative tests Resisted forearm pronation for 30 to 60 seconds demonstrates compression at pronator teres when symptoms are reproducedResisted elbow flexion and supination of the forearm can localize compression to lacertus fibrosisResisted long-finger flexion localizes lesion at level of flexor digitorum superficialis (FDS) arch Supracondylar process can be palpated on medial humeral surface and confirmed with radiographsEMG/NCV is inconsistent and diagnosisshould be made clinically*

Lacertus FibrosisThe lacertus fibrosis can be deformed by trauma, repetitive stress, or imbalance of triceps and biceps brachiiBiceps brachii is elbow flexor and most powerful forearm supinator can be inhibited by over-facilitated triceps due to pancreatic hyperfunction Hyperinsulinism very common!

*

Supinator SyndromeEntrapment of Radial nerve beneath Supinator muscle Symptoms with repetitive forearm motionsesp. throwingDecreased hand strength, pain deep in posterior forearmWeakness of extensor carpi ulnarisStrengthens with approximation of proximal radius and ulna or with lower arm in full supinationZatkin/Stark 2007*

Zatkin/Stark 2007

Supinator Syndrome

Test Supinator for normal functionespecially fascial involvement Test for core muscle dysfunctionEsp transverse abdominisZatkin/Stark 2007*

Zatkin/Stark 2007

Ulnar Sulcus Syndrome

Entrapment of ulnar nerve in ulnar sulcus of medial epicondyle of humerusdue to laxity or enlargement of epicondylo-olecranon ligament

Symptoms of numbness/tingling and/or pain in ulnar nerve distribution

Zatkin/Stark 2007*

Zatkin/Stark 2007

Ulnar Sulcus SyndromeWeakness of flexor carpi ulnaris in elbow flexion but usually not in extensionChallenge humerus and ulna and adjustTest ligament for fascial shortening and raw bone supplementation

Zatkin/Stark 2007*

Zatkin/Stark 2007

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