elbow conditions pronator teres syndrome supinator syndrome ulnar sulcus syndrome see leaf and...

Elbow ConditionsElbow Conditions

Pronator Teres syndromePronator Teres syndrome

Supinator syndromeSupinator syndrome

Ulnar sulcus syndromeUlnar sulcus syndrome

SEE LEAF and WALTHER MANUALSSEE LEAF and WALTHER MANUALS

FOR IN DEPTH DISCUSSIONFOR IN DEPTH DISCUSSION

©Zatkin/Stark 2007©Zatkin/Stark 2007

Pronator Teres SyndromePronator Teres Syndrome

Entrapment of Entrapment of Median nerve Median nerve between ulnar and between ulnar and radial heads of Pronator Teres muscleradial heads of Pronator Teres muscle

– most common site of compression caused by muscle most common site of compression caused by muscle hypertrophy or thickening of aponeurotic fascia hypertrophy or thickening of aponeurotic fascia between two heads of pronator teresbetween two heads of pronator teres

Median nerve enters forearm passing between the Median nerve enters forearm passing between the two heads of pronator teres and then deep to two heads of pronator teres and then deep to flexor digitorum superficialis arch, continuing flexor digitorum superficialis arch, continuing between flexor digitorum superficialis and flexor between flexor digitorum superficialis and flexor digitorum profundus in forearmdigitorum profundus in forearm


Pronator Teres Syndrome…Pronator Teres Syndrome…

There are four reported sites of median nerve There are four reported sites of median nerve compressioncompression

1.1. pronator teres: most commonpronator teres: most common

2.2. flexor digitorum superficialis arch: second most flexor digitorum superficialis arch: second most common, fibrosis of flexor digitorum superficialis common, fibrosis of flexor digitorum superficialis arch arch

3.3. supracondylar process/ligament of struthers supracondylar process/ligament of struthers

4.4. lacertus fibrosis (bicipital aponeurosis) lacertus fibrosis (bicipital aponeurosis)

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Lacertus FibrosisLacertus Fibrosis

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

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Symptoms of decreased hand strength, problems with writing, Symptoms of decreased hand strength, problems with writing, numbness/tingling in hand and especially palm, pain in proximal numbness/tingling in hand and especially palm, pain in proximal forearm, fatigue with exerciseforearm, fatigue with exercise

– Signs and symptoms usually worse Signs and symptoms usually worse with activitywith activity

– Nocturnal symptoms seen with carpal tunnel syndrome are typically absentNocturnal symptoms seen with carpal tunnel syndrome are typically absent

– Negative Phalen's test Negative Phalen's test

– Weakness of median innervated muscles may only appear after Weakness of median innervated muscles may only appear after provocative tests (resisted pronation)provocative tests (resisted pronation)

Weakness of Weakness of finger flexors finger flexors (ie: flexor digitorum profundus) (ie: flexor digitorum profundus)

– Strengthens with approximation of proximal radius and ulnaStrengthens with approximation of proximal radius and ulna



Weakness of Weakness of finger flexors finger flexors (ie: flexor digitorum (ie: flexor digitorum profundus) profundus)

– Strengthens with approximation of proximal radius Strengthens with approximation of proximal radius and ulnaand ulna



1.1. Challenge radial head and adjust Challenge radial head and adjust – Often superior or lateralOften superior or lateral

2.2. Test Pronator teres for proper function Test Pronator teres for proper function – Weakness Weakness – Shortened : SCS/RSCS, FF, etcShortened : SCS/RSCS, FF, etc– Test for core muscle dysfunctionTest for core muscle dysfunction

Esp transverse abdominisEsp transverse abdominis


Median Nerve Provocative tests Median Nerve Provocative tests

– Resisted forearm pronation for 30 to 60 seconds Resisted forearm pronation for 30 to 60 seconds demonstrates compression at pronator teres when demonstrates compression at pronator teres when symptoms are reproducedsymptoms are reproduced

– Resisted elbow flexion and supination of the forearm Resisted elbow flexion and supination of the forearm can localize compression to can localize compression to lacertus fibrosislacertus fibrosis

– Resisted long-finger flexion localizes lesion at level of Resisted long-finger flexion localizes lesion at level of flexor digitorum superficialis (FDS) arch flexor digitorum superficialis (FDS) arch

– Supracondylar process can be palpated on medial Supracondylar process can be palpated on medial humeral surface and confirmed with radiographshumeral surface and confirmed with radiographs

– EMG/NCV is inconsistent and diagnosis should be EMG/NCV is inconsistent and diagnosis should be made clinicallymade clinically

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Lacertus FibrosisLacertus Fibrosis

The lacertus fibrosis can be deformed by The lacertus fibrosis can be deformed by trauma, repetitive stress, or imbalance of trauma, repetitive stress, or imbalance of triceps and biceps brachiitriceps and biceps brachii

Biceps brachii is elbow flexor and most Biceps brachii is elbow flexor and most powerful forearm supinator powerful forearm supinator

– can be inhibited by over-facilitated triceps due can be inhibited by over-facilitated triceps due to pancreatic hyperfunction to pancreatic hyperfunction

– Hyperinsulinism very common! Hyperinsulinism very common!

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Supinator SyndromeSupinator Syndrome

Entrapment of Entrapment of Radial nerve Radial nerve beneath Supinator beneath Supinator muscle muscle

Symptoms with repetitive forearm motionsSymptoms with repetitive forearm motions

– esp. throwingesp. throwing

Decreased hand strength, pain deep in posterior Decreased hand strength, pain deep in posterior forearmforearm

Weakness of Weakness of extensor carpi ulnarisextensor carpi ulnaris

– Strengthens with approximation of proximal radius Strengthens with approximation of proximal radius and ulna and ulna oror with lower arm in full supination with lower arm in full supination


Supinator Syndrome…Supinator Syndrome…

Test Supinator for normal functionTest Supinator for normal function

– especially fascial involvement especially fascial involvement

– Test for core muscle dysfunctionTest for core muscle dysfunction

Esp transverse abdominisEsp transverse abdominis


Ulnar Sulcus SyndromeUlnar Sulcus Syndrome

Entrapment of Entrapment of ulnar nerve ulnar nerve in ulnar sulcus in ulnar sulcus of medial epicondyle of humerusof medial epicondyle of humerus– due to laxity or enlargement of epicondylo-due to laxity or enlargement of epicondylo-

olecranon ligamentolecranon ligament

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


Ulnar Sulcus Syndrome…Ulnar Sulcus Syndrome…

Weakness of Weakness of flexor carpi ulnaris flexor carpi ulnaris in elbow in elbow flexion but usually not in extensionflexion but usually not in extension

– Challenge humerus and ulna and adjustChallenge humerus and ulna and adjust

– Test ligament for fascial shortening and Test ligament for fascial shortening and raw raw bone bone supplementationsupplementation


elbow conditions pronator teres syndrome supinator syndrome ulnar sulcus syndrome see leaf and...

Documents

test pronator teres

flexor digitorum profundus

forearm zatkinstark

proximal forearm

forearm pronation

posterior forearm

supinator muscle symptoms

powerful forearm supinator