In the previous article, we introduced differences between pronator syndrome and carpal tunnel syndrome. We also learned in recent studies, 50% of pronator syndrome patients can recover in 4 months with conservative treatments (such as cortisone injection and rehabilitation).
This time we are going to talk about the physical examinations and rehabilitation for pronator syndrome.
⭐ Physical Examination
* The Pronator Compression Test: Placing pressure over the pronator muscle in both upper extremities. A positive test is indicated by reproduction of tingling and numbness in the first 3 1⁄2 digits within 30 seconds.
There are 3 other physical examinations that help to determine the site of median nerve compression.
1. Elbow bending in 90°, then turn the forearm in a resisted pronation, and gradually extend the elbow. If pain and neuropathic symptoms reproduced, the pronator teres muscle is implicated the source of compression.
2. Hold middle finger for a resistive bending of the middle joint (PIP). If pain and neuropathic symptoms reproduced, the flexor digitorum superficialis (FDS) is involved as the source of compression.
3. Hold the elbow in 120° to 130° flexion with resistance and keep forearm in maximal supination. If pain and neuropathic symptoms reproduced, it indicates the lacertus fibrosus is the site of compression.
⭐ Rehabilitation for Pronator Syndrome
Rehabilitation for this nerve entrapment issue should include: resting, therapeutic exercises, myofascial release and kinesio taping.
It is essential to stop overusing the affected arm for repetitive grasping and forceful forearm rotation. Therefore, an elbow orthosis (brace) can be helpful to rest the elbow in bending, and forearm in mid rotation (neutral) position. It should be worn all the time for at least 2 to 4 weeks.
For heavy computer users, you should consider using an ergonomic split keyboard and vertical mouse, which greatly reduce full pronation of your forearm when tying and mousing. (see the details of ergonomic recommendation here)
* Therapeutic exercises
1. Median Nerve flossing
You will find many videos online that claim to help gliding/flossing your median nerve, so far the most accurate and thorough median nerve flossing exercises I can find is from Dr. Jo (DPT).
2. Pronators Stretching
* Stand with your back facing the doorframe.
* Raise you arm behind (shoulder extension) about 75° , keep the elbow straight.
* Grasp the doorframe with your thumb pointing down.
* Externally rotate the arm (roll your biceps toward the top).
3. Flexors Stretching
Make sure your palm is facing up (supination) when stretching your flexors.
* Myofacial Release
Self myofacial release technique for pronator teres muscle:
1. Keep your elbow bending, palm facing up. Put your thumb over the affected forearm, close to elbow (pic 1)
2. Turn your palm facing down, it will activate the pronator teres muscle so you can locate the muscle belly. (pic 2)
3. Once your thumb find a sore and tender spot, keep pressing for 5 seconds without triggering any tingling or numbness sensation.
4. Rotate your forearm (turning your palm up and down) 10 times while you thumb is still on the spot. (pic 2 & 3)
5. After rotating, follow along the muscle fiber to find another sore spot, repeat the same technique.
* Kinesio Taping
1. Anchor the tape over outside of mid forearm, then stretch it diagonally (30% tension) towards inside of the forearm
2. Anchor the tape over pinky side of the wrist, then stretch it (30% tension) towards inside of the elbow.
In summary, pronator syndrome happens when your median nerve is trapped in your proximal forearm. It is usually under-diagnosed due to its similar symptoms of carpal tunnel syndrome.
Although this is a less common condition compared to other nerve entrapment issues, I hope this article helps you to detect the problem early and treat the real culprit. Finally, rehabilitation for pronator teres syndrome should consist of resting, therapeutic exercises, myofascial release & kinesio taping.
* Dididze M, Sherman Al. Pronator Teres Syndrome. [Updated 2020 Jan 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526090/
* Lee, M. J., & Lastayo, P. C. (2004). Pronator Syndrome and Other Nerve Compressions That Mimic Carpal Tunnel Syndrome. Journal of Orthopaedic & Sports Physical Therapy, 34(10), 601–609
* Nelson, A. G., & Kokkonen, J. (2021). Stretching anatomy. Champaign, IL: Human Kinetics.
* Skirven, T. M. (2011). Rehabilitation of the hand and upper extremity. Philadelphia, PA: Elsevier/Mosby.