;ry "

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Copyright1981by The Journalof Boneand Joint Surgery,Incorporated

hy
ar-
ior
The Pronator Teres Syndrome:
tal
.~nt
Compressive Neuropathy of the MedianNerve*
dl, BY CHARLES R. HARTZ, M.D.’~, RONALD L. LINSCHEID, M.D.’~, R. REED GRAMSE, M.D.’~,
AND JASPER R. DAUBE, M.D.J’, ROCHESTER, MINNESOTA
ior
From the Departments of Orthopedics, Physical Medicine and Rehabilitation, and Neurology,
in
MayoClinic and MayoFoundation, Rochester
at-
~re
ABSTRACT:Thirty-nine patients with a clinical gically g, an anomalous fibrous band that compressed the
the
diagnosis of the pronator teres syndrome were seen median nerve was identified and cut. Since then, the syn-
during a seven-year period. They typically complained drome has been recognized with increasing frequen-
FIS,
of aching discomfort in the forearm, weakness in the cy2,’,’,9,1e,
¯ it
hand, and numbness in the thumb and index finger. We are reporting a study of thirty-nine patients in
as
Cyclic stress usually brought on the symptoms. The whomwe diagnosed the pronator teres syndrome and at-
the
distinctive physical finding was tenderness overthe tempted to identify the factors by which one can differ-
’ tO
proximal part of the pronator teres, which was aggra- entiate this disorder from other lesions.
SO
vated by resisted pronation of the forearm, flexion of
To Clinical Material
the elbow, and occasionally by resisted contraction of
~al-
the flexor superficialis of the long finger..Elec- From 1972 to 1979, thirty-nine patients seen at the
der
trophysiological testing of the median nerve showed Mayo Clinic were diagnosed as having the pronator teres
caft
abnormalities in a few patients, but localization of the syndrome. Preoperatively and postoperatively, all of the
der
abnormality was possible only rarely. Intraoperative patients were examined by one or two of us (C. R. H. and
recordings showed some improvement shortly after R. L. L.). Twenty-nine patients were female and ten were
release of the median nerve in six of the ten forearms male; their ages ranged from fourteen to seventy-eight
that were tested. Surgical exploration of thirty-six years. The criteria for diagnosis were symptoms and signs
forearms in thirty-two patients showed intramuscular of a median neuropathy localized to the forearm and hand:
tendinous bands in the pronator, indentation of the aching discomfort and easy fatigability of the muscles
muscle belly of the pronator teres by the lacertus fi- of tile forearm brought on by cyclic stress, and indentation
brosus, or a taut tendinous origin of the flexor super- and tenderness of the pronator teres muscle. With repeti-
ficialis in most forearms. Vascular and muscular tive pronation the patients also had numbness in the dis-
abnormalities were seen occasionally. Of the thirty-six tribution of the median nerve in the hand; the nu__mbness
operations, twenty-eight gave good or excellent results; seldom was well localized, although it tended to involve
five, fair; "and in three patients the symptoms were un- the index finger and thumb and first was noticed after the
changed. The cause of failure was either inadequate discomfort became evident. Nocturnal awakening because
decompression or misdiagnosis. ~3f pain as well as numbness in the hand in the morning,
commonly associated with the carpal tunnel syndrome,
Compressive neuropathy of the median nerve in the typically was absent. The duration of symptoms averaged
arm and forearm Can be a difficult diagnostic and thera- twenty-three months (range, one to 120 months). The
peutic challengeZ’V’a’12~ It must be distinguished from cer- symptoms usually began insidiously, but occasionally
vical radiculitis, the thoracic outlet syndrome, brachial after a specific muscle sprain or episode of activity their
plexus neuritis, overuse of the muscles of the forearm, and onset was rapid and dramatic. The symptoms frequently
carpal tunnel syndrome. In 1951, Seyffarth described a began during activities that required repetitive grasping or
group of seventeen patients with symptoms that he con- pronation, or both (for example, prolonged hammering,
sidered to be caused by compression of the median nerve scraping dishes, ladling food, or practicing tennis serves).
in its course through the pronator teres muscle. In the first One of our patients had a rather sudden onset of symptoms
patients with pronator teres syndrome to be treated sur- of the pronator teres syndrome in a forearm affected by
spastic hemiparesis. Previously he had had a tendon trans-
* Read at the Annual Meeting of The American Orthopaedic As- fer from the flexor digkorum superficia~is to the pr~3fundus
sociation, San Juan, Puerto Rico, June !8, 1979, and a ieng~hening of the flexor carpi radia!is. It ’,~..’as be-
~" Mayo Clinic. 2!30 First Street S.W., Rochester. Mklnesota
55~05. P!~ase addv~Ss r~r.ri~:t requests ’:o Dr. Hartz, c/o Secti:~ ~f Pub- !ieved ~hat the dorsiflexion of th,~ wris~ ai]o,ve~ by the

VOL. 63-A, NO. 6, JULY1981 885

886 C.R. HARTZ, R. L. LINSCHEID, R. R. GRAMSE, AND J. R. DAUBE

der the taut origin of the flexor digitorumsuperficialis. We nerve at the level of the pronator terns, and electromyo-
had no patients with po~t-traumatic syndromes in our graphic abnormalities limited to muscles innervated by the
series. The lack of specificity of the symptomsand the median nerve, were considered definitive electrophysi-
subtlety of the physical findings in-several patients led to ological findings for the pronator terns syndrome. In-
suspicion of either functional neurosis or conversion hys- traoperative recordings from the median nerve were made
teria. Sevenpatients had had misdiagnosesthat had led to in ten forearmsin eight patients in an attempt to identify a
carpal tunnel release, and one of them had had an ulnar more localized abnormality than could be detected witti
transposition operation without relief of symptoms. The routine recordings, and to record any electrophysiological
previous operations were done between three and twenty- changes in the nerve after decompression. Direct in-
eight monthsbefore our initial examination. traoperative measurementsof mixed nerve-action poten-
The physical findings in the seven patients whowere tials were madefrom the exposed nerve both proximal and
not operated on and in the thirty-two whowere operated on distal to the pronatorterns before and after surgical release
differed only in degree. The outstanding positive finding of compression on the median nerve. Nerve-action poten-
was tenderness in the proximal part of the pronator teres tials were stimulated and recorded using hand-held
muscle, which was noted in thirty-seven patients. In the silver-hook pairs of electrodes with the nerve elevated
other two patients, this symptommay have been present away from surrounding tissue. Stimulation was applied
but it was not noted. Wefound tenderness in the median distally in the forearm while recording was done proximal
nerve in the antecubital space in thirty-one patients, while to the pronator teres muscle. Recordings were made be-
tenderness was noted distally less frequently. Thirty pa- fore, immediatelyafter, and fifteen to twentyminutes after
tients experienced paresthesias in the distribution of the surgical decompressionof the nerve. Distances along the
median nerve and the hand when the forearm was pronated nerve betweenthe stimulating and the recording electrodes
forcibly against resistance. A positive Tinel sign at the were measuredwith a millimeter ruler to allow calculation
proximal edge of the pronator teres was elicited in twenty of velocities fromthe latencies of the initial-positive peak.
patients. Fourteen patients suffered exacerbation of the Amplitudes were measured from peak to peak.
paresthesias whenthe flexors of the long finger were con-
tracted against resistance. In seventeen patients, the pro- Treatment
nator muscle was observed to be unusually firm compared Seven patients considered that their symptomswere
with the contralateral muscle. A depression in the contour not severe enough to justify an operation. Anexplanation
of the forearm superficial to the lacertus fibrosus was obvi-of the probable cause for the symptomsand steps that
ous in three patients. Mild thenar atrophy was present in could be taken to minimize them, including job
only three patients, and the Tinel test was rarely positive at
modifications, were given. Surgical exploration was per-
the wrist, although nineteen patients had a positive Phalen formedin thirty-two patients (thirty-six forearms). In all
sign at the wrist. Hypohidrosisin the distribution of the thirty-two patients, cutaneous sensory nerves of the arm
median nerve, which is commonin the carpal tunnel syn- and forearm were identified and protected. Weinspected
drome, was not found in any of our patients. the lacertus fibrosus, assessed its thickness, and deter-
minedwhether it indented the antebrachial fascia-over the
Electrical Studies pronator, especially during passiv e pronation and exten-
El.ectromyography was done on forty forearms in sion. Then the course of the median nerve was noted, and
thirty-eight patients. One patient had had an electromyo- it wasfreed along the radial border. The relationship of the
graphic study at another institution six months before an nerve to the pronator teres was assessed. Intramuscular
unsuccessful carpal-tunnel release, and the test was not re- tendinous bands within or under the pronator and fascial
peated. All patients had bilateral measurements in the constricting bands betweenthe superficial and deep heads
ulnar and median motor and sensory nerves. Wemeasured of the muscle were released from the accompanyingradial
the compound muscle and nerve-action potentials artery, as were vascular leashes or penetrating vessels.
(amplitude and latency) from the thenar muscles and index The anterior interosseus nerve was identified and protected,
finger during stimulation of the mediannerve at the wrist as was the arch of the flexor digitorum superficialis. If
and proximal to the pronator teres muscle. Nine of the there was a tight falciform edge, it was split carefully to
thirty-eight patients studied electromyographically had expose the mediannerve as it penetrated deep to the mus-
measurementsof segmental conduction velocity across the cle; all motor branches to the musclewere protected..
Pronator muscle by needle-electrode stimulation; in an Postoperative care consisted of immobilization of the
additional sixteen studies, the sensory-nerve conduction arm in a paddedplaster splint for two or three weeks, fol-
velocity was measuredin the mediannerve of the forearm, lowed by mobilization of the elbow and strengthening of
including the segmentthrough the pronator teres. Electro- the muscles with activities added as tolerated. Weadvo-
myogramswere made of sew~rai muscles that arc cated avoidance of strenuous work for six weeks. Occa-
vated by the mediannerve. A slowing of co~du,.::i,.~c ve- si,onally a patient needed supervised physical thc=:~py be-
locity of moreth~ ten meters per secondor ~. ::,! .:.:.: c:~c~seof dif~ct:ityia m,.)bi{izing,,.-,~ >:rcng~b,
eni :!: ~;e el-
conduction in the motoror sensory fibers in t_~>: bow.
 THE PRONATOR TERES SYNDROME 887
lyo- Results excellent results werea taut lacertus fibrosus, an intramus-
’ the
Evaluation of positive intraoperative findings de- cular tendinous abnormality about the median nerve, and
~ysi-
pended On the surgeon’s experience and judgment, and tightness at the arch of the flexor digitorum superficialis.
[n-
:tade probably improvedduring the course. Of the study. In sev- The patients with fair or unchangedratings usually had
fya eral patients more than one abnormality was found¯ Six- less conspicuouslesions, although in all three patients who
teen patients (sixteen forearms) had a hypertrophied pro- had unchangedratings at least one anatomical abnormality
¢¢ith
nator muscle or a tendinous band in the pronator capable of was identified. Twoof these three patients, however,later
~ical
constricting the median nerve: fifteen had a thickened required care for emotional disorders, and in the third an
in-
lacertus fibrosus that appearedto indent the flexor muscle undiagnosed neural disease appeared to have developed.
ten-
mass; and twelve patients had a taut fibrous arch of the
and Electrodiagnosis
flexor digitorum superficialis. In six patients, the median
.~ase
nerve passed posterior to the ulnar head of the pronator. Amongthe results from forty standard electrical
ten-
One patient with bilateral symptomshad a large pronator studies, the meanvalues for amplitudes and velocities of
add
muscle with an extended proximal origin in each forearm, the median motor and sensory nerves in the entire group
ated
as well as tight ligamentous bands extending from the were abnormal (velocities of 58.0 _ 1.1 and 62.1 _+ 1.0
lied
medial intermuscular septumto the pronator fascia. These meters per second, respectively), but only twelve (30 per
mal
bands simulated the ligament of Struthers and they com- cent) of the forearms showed values outside the normal
be-
pressed the nerve at the point of entrance to the pronator. range. Of these, only six had evidence of a proximal le-
~fter
One patient had a large vascular structure penetrating sion in the median nerve on standard studies. The changes
the
through the nerve and another had a bursa on the insertion were elicited primarily by needle-electrode examination.
~des
of the biceps that measured two centimeters in diameter Two(22 per cent) of the nine patients whohad mea-
tion
and compressed the nerve. In two patients, no abnor- surements of segmental motor-nerve conduction velocity
ink.
malities were recognized. showed local slowing or a block at the pronator teres.
The seven patients who were not operated on were None had dispersion of evoked responses. Evidence of
followed for five to seventy-two months (average. segmental compression of the sensory part of the median
twenty-eight months): two improved, four were un- nerve during its course through the pronator teres was
lere
changed, and one was worse. The improvementin the two sought in twenty-five patients and was elicited in four (16
tion
patients was attributed to job modifications that allowed per centl. Four other patients showed other, non-
that
occasional rest periods and less repetitive use of the hands. diagnostic abnormalities.
job but neither patient was always free of symptoms¯The four A total of nine patients had electromyographic ab-
~er- patients whose condition was unchangedhad adapted their normalities suggestive of damage to the median nerve
all jobs or activities to minimizetheir symptoms.At the time proximal to the wrist: five had abnormalities on the
trm of writing, the one patient (a dentist) whowas worse was needle-electrode examination of muscles, four had delays
:ted " considering undergoing an operation. in sensory conduction (all mild), and two had abnormali-
ter- Postoperative follow-up in the thirty-two patients ties on motor conduction studies (Table I).
the ranged from three to eighty-eight months and averaged
:en- eighteen months. Wedefined an excellent result as no re-
and TABLE I
sidual pain, paresthesias, or weakness and no hypohi-
the Electromyographic Patients Not Result(No.)
drosis, muscle atrophy, or diminished sensibility. A good
~lar Findings Operated On Good Fair Poor Total
result meant that most symptomswere relieved and the (No.)
cial patient could pursue all previously limited activities in
ads spite of the fact that a mild weakness, minimumpain, and Totalof forearms* 7 24 6 3 40
:lial Normal 7 12 4 2 25
some paresthesias of a non-disabling degree often were Pronatorteres syndrome 0 1
els. I 0 2
present. A fair result meant that the patient was able to Proximalmedian-nerve
:ed, damage 0 8 1 0 9
workat least part-time but had residual episodes of dis-
¯ If Carpaltunnelsyndrome 0 5 I 1 7
ability.
i to
The results were excellent in eight forearms, goodin * Somepatientshadtwotypesof abnormality.
US-
twenty, and fair in five~ The condition of three patients
was unchanged. One patient whose condition improved Only two patients had definite electrophysiological
from fair to good had anomalousmuscles and a small me- evidence of pronator teres syndrome. Seven patients had
dian nerve. Postoperatively, she had someweaknessof the electromyographic evidence diagnostic of carpal tunnel
finger flexors and paresthesias in the hand¯ These gradu- syndrome(Table I). and one of these also had evidence
ally resolved during an eight-month period, but some
changes in a more proximal part of the nerve. One patient
weaknessduring pronation persisted. Another patient had had unusual findings: dense fibrillation potentiai~ in the
a goodresult in the right arm but only a fair result in the
pronator teres muscle.
left arm.
Ten patiems had i>:ra~perafive e!ectrophy:-:i,v!ogical
The most commonlesions in the patients with good or studies. On standard electromyographic studies in these

VOL. 63-A, NO. 6. JUI.y 198t

888 C.R. HARTZ, R. L. LINSCHEID,
patients, five of the recordings were normal, one showed
slow sensory conduction velocity, three showed proximal
changes on needle-electrode examination, and four had
evidence of the carpal tunnel syndrome. None showed
clear-cut electrophysiological evidence of neuroi~athy of
the median nerve at the pronator muscle. Conduction ve-
locities recorded intraoperatively were within the expected
normalrange in nine of the ten patients (fifty-six to sixty-
eight meters per second), while one patient had slow con-
duction (forty-eight meters per second). Three of the ten
patients showed an improvementof five meters per second
or more after decompression, and seven had conduction
velocities that were unchanged.
Measurementsof amplitudes of nerve-action poten-
tials ranged widely, but three increased 50 per cent or
more after decompression, and none decreased by more
than 20 per cent. All ten patients had goodto excellent re-
sults after the operation.
Subsequent Operations
Six patients had additional operations after the initial
so-called index operation for the pronator teres syndrome.
The first patient was essentially symptom-freefor three
years, and then the symptomsrecurred. Re-exploration re-
vealed that the arch of the flexor digitorum superficialis
was markedlytight, a finding that was not observed at the
first operation forty-four months earlier. Her condition
was improved on follow-up examination, six months after
the second operation. The second patient had no sig-
nificant relief from the original operation. Re-exploration
eight monthslater disclosed that the tendon from the ulnar
head of the pronator ~eres lying beneath the nerve acted as
a sharp-edged, compressive structure when the forearm
was pronated. This tendon was released, and the symp-
toms were alleviated. The third patient had two operations
for carpal tunnel release after the index procedure on the
pronator teres:. The first release was performedon the left
side six monthsafter the index operation, and the second
was done on the right side sixteen monthsafter the pronator
release. Symptomsof the pronator teres syndrome had
been relieved by the index operation. The patient and the
examiner both considered that the symptomsof the carpal
tunnel syndrome differed from the earlier symptoms.The
fourth patient underwentexploration of the carpal tunnel
seventeen monthsafter the release of the pronator teres.
The mediannerve was normalat the wrist, but a functional
anastomosis was found between the flexor pollicis longus
and the flexor digitorum profundus tendon of the index
finger (Linburg’s syndrome). This anastomosis was re-
leased and there was subsequent resolution of the symp-
toms. In the fifth patient, a symptomaticbilateral ulnar
neuropathy developed six years after she had an excellent
result from the operation on the pronator teres. She had an-
terior transposition of both ulnar nerves ninety-one monihs
after the pronator release. Five years after the index oper-
ation the sixth patient, underwentfusion of the sixth and
seventh cervical vertebrae for symptoms of cervical
R. R. GRAMSE, AND J. R. DAUBE
radiculitis, unrelated to the pronator teres syndrome. teres
a supi
Discussion
Ten&
The pronator teres syndrome can be produced by one hemir
or more abnormalities that frequently are subtle and re- under
quire judgmentsthat are not quantified easily. Constriction our p:
of the nerve is different from that seen in the carpal tunnel I
syndrome. Of the thirty-six median nerves that we varia~
explored, sixteen were constricted by fascia1 or tendinous the r(
structures in the pronator teres. The lacertus fibrosus ap- passe
peared to be a cause of constriction in fifteen forearms, and per c~
the superficialis arch was taut in another thirteen. The in- per c:
cidence of the apparent causes of this syndromein our se- cent,
ries parallels the experience of Johnsonet al.
Seyffarth described seventeen patients who had medi~
weaknessof opposition and hyperesthesia of the ulnar bor- Six c
der of the thumband radial border of the index finger. This nott:
combination of symptomswas distinctly unusual in our serti:
experience. Injections of procaine hydrochloride into the
pronator teres muscle produced partial or complete relief and
in a numberof his patients at the time of follow-up, seyf- expk
farth believed that the "pressure of work" from writing or thou
from the tight gripping and turning of tools resulted in a WaS
hard, painful pronator muscle and caused the syndrome." nerv,
Hypertrophy of the muscles of the volar part of the the r
forearm related to workappears to be a factor in the etiol- For
ogy of the pronator teres syndrome. The pronator muscle caus
maybe overdeveloped during repetitive activity, so that
6.
the lesion represents a dynamic compartmentsyndrome fore~
The muscular induration seen on the symptomatic forearm caus
and the indentation of the flexor pronator mass by the
lacertus in someof our patients suggest that there is mus- easy
cular hypertrophy within a fascial compartment. A recent tient
exampleof this in our patients was a school-bus driver who bet~
had sprained his thumb. The cast that was applied necessi- exaF
tated his gripping the steering wheelwith only the fingers.
This led to a rather acute pronator teres syndromein a few leas,
days, which subsided with rest. Recent work has lent
suggested that the pressures in the proximal muscle com-
partment should be measured to assess the role of in- a pk
creased pressures in the etiology of the pronator teres syn-
drome 6. It is possible that fasciotomyin the proximalpart velo
of the forearm maybe a significant factor in the favorable have
response to treatment. sync
Spinner noted acute syndromes in patients who were corn
undergoing renal dialysis and anticoagulant therapy, and
others have described patients with the syndromedue to accc
trauma4"~, but neither of these causes for the syndrome flew,
was evident in our patients. Spinner thought that resisted ficia
flexion and supination of the elbowseemedto significantly
exacerbate symptomscaused by a tight lacertus fibrosus.
Wenoted intraoperatively that the lacertus appears to
compressthe pronator teres during passive pronation, ap-
parently because the tendon of the biceps movesdistally, SCT
drawingthe origin of the iacertus with it.
Of ten patients in the series of Bell and Goldner, in
fo,ar who had cerebral p~sy symptoms of &e pronator
THE JOURNAL OF BONE AND JOINT SURGERY
 THE PRONATOR TERES SYNDROME 889
teres syndrome developed when the arm was placed in preoperatively, as do a moderate number of patients who
a supination cast for pronation contracture of the forearm. are asymptomaticpostoperatively.
Tendon-lengthening in another patient with spastic Twoelectromyographic studies of the pronator teres
hemiparesis apparently pulled the median nerve, tautly syndromehave been reported. Buchthal et al. found only
underthe superficialis, a situation similar to that in one of minimumabnormalities in eleven patients. Three patients
our patients. had abnormal nerve-conduction studies, while all eleven
In 1939, Beaton and Ansondelineated the anatomical had abnormal needle electromyograms. Morris and Peters
variations of the pronator teres, with special attention to noted abnormal motor conduction in six of eight involved
the route of the median nerve. They found that the nerve arms in patients whohad significant motor and sensory
passed between both heads of the pronator muscle in 82.5 deficits on neurological examination.
per cent of 240 arms, below a solitary humeralhead in 8.8 The results of electrophysiological testing in our pa-
per cent, and below both heads in 6.3 per cent. In 2.5 per tients were similar to those reported by Buchthalet al. The
cent of the arms the nerve pierced the humeral head. motor and sensory conduction velocities and amplitudes
Spinner discussed the case of one patient in whomthe for the median nerve were significantly although mildly
mediannerve ran posterior to both heads of the pronator. reduced, particularly in patients with more severe symp-
~Six of our patients appeared to have this finding. Wedid toms. In most patients, therefore, the nerve was not af-
not try to reroute the mediannerve subcutaneouslyby rein- fected severely enoughto result in conduction values out-
serting the pronator teres, as suggested by Spinner. side the normal range, and the mildness of the abnormality
Solnitzky believed that the variability of symptoms was consistent with the minimumneural deficit. The
and physical findings in the pronator teres syndromewas findings were probably due to the intermittent compression
explained by changes in patterns of rest and activity. He of the nerve and possibly to a selective involvementof the
thought that the variability in the sensory and motor signs small pain fibers. The nerve-conduction findings and the
was due to the functional groupings of fibers within the frequency of abnormal studies on needle examination in
nerve and the location of the compressingagent relative to this disorder resemble the signs of traumatic neuropathies
the nerve. Our experience seems to support this concept. more than those of chronic compressive neuropathies.
For example, compression of the median nerve that was Chronic compressive neuropathies typically are charac-
caused by a tight lacertus fibrosus in our patients resulted terized by either local slowing of conduction or a conduc-
in pain that spread diffusely in the volar aspect of the tion block due to segmental demyelination and axonal nar-
forearm, while compression by a tight superficialis arch rowing, while traumatic neuropathies more commonlyre-
caused more localized pain. sult in axonal loss with low-amplitude responses. This
Diagnosis of the pronator teres .syndrome seldom is type of pathological change also is consistent with our in-
easy. This point is illustrated by the cases of the seven pa- ability to localize the damageelectrophysiologically in
tients in our group who had had unsuccessful operations most patients. ~
between three and twenty-eight monthsbefore our initial The large number of normal electromyographic
examination. findings in our patients indicates that electromyography
Five patients required a subsequentoperation after re- cannot exclude the diagnosis of the pronator teres syn-
lease of the pronator teres that initially gave goodor excel- drome, nor can it predict the outcome of operation. The
lent results. Asidefrom the possibility of error in the orig- entirely normal electromyographicfindings in the patients
inal diagnosis or the existence of someuncorrected lesion,
whowere not operated on may have influenced this group
a plausible reason for the secondoperation in one patient of patients not to have an operation, and that.fact maybe
was that an unrelated ulnar neuropathy might have de- important in the evaluation of electromyogi:aphic tests.
veloped. In three patients a carpal tunnel syndromemay However,in patients with suspected pronator teres syn-
have coexisted with or developed after the pronator teres drome, electrophysiological testing was of value for two
syndrome,perhaps in a nerve rendered more susceptible to specific purposes: (1) it distinguished other peripheral
compressionin the carpal tunnel. Inadequate release of the nerve disorders that present with similar symptoms, and
compressingstructures at the initial exploration mayhave (2) it showedthat a non-localizable median-nervelesion
accounted for the recurrence of symptomsin the fifth pa- was present in 15 to 20 per cent of the patients with the
tient. Althougha constricting fascial band and the super- syndrome, and in a smaller percentage it accurately lo-
ficialis arch werereported to be divided at the first opera- calized the lesion.
tion, at re-exploration the superficialis arch again was
Identification and localization were enhancedby all
foundto be tight.
three types of electrophysiological study -- motor and
Lister comparedthe diagnosis of the pronator teres sensory conductions across the pronator and needle elec-
syndromewith that of the carpal tunnel syndrome.He de--
tromyograms of the forearm and hand muscles. As no one
scribed features commonto both but noted that the pro-
study was superior to the other two, all are neededin test-
nator teres syndromewas not associated with a positive
Phalrn test. Our experience does not confirm his assertion. ing for the pronator teres syndrome.Precise localization in
51~’ty per cent of our patients had a positive Pha!en test a few patients was ?ossib!e wi~hconductionstuc’ies across
short segmentsbut it was not of value unless an abnormal-
VOL. 63-A, NO. 6. JULY
890 C. R. HARTZ, R. L. LINSCHEID, R. R. GRAMSE, AND J. R. DAUBE

ity was found on standard studies. The results of the in-
traoperative electrophysiological recordings were similar
to those of preoperative studies: they showedonly mild
abnormalities that did not identify or localize the damage
any better than did standard studies. However,after de-
compression of the nerve the change in conduction veloc-
ity and in amplitude of the nerve-action potentials mea-
sured intraoperatively in somepatients was evidence that
there was an improvementin nerve function.
Someof the patients who improved after operation
had clear-cut electromyographic evidence of other disor-
ders -- carpal tunnel syndromein seven patients and an
upper-arm median neuropathy in one other patient. This
implies that the pronator teres syndromemaycoexist with
other median neuropathies or that these other disorders
may improve after decompression of the proximal median
nerve.
The fact that increased latencies in conduction in the
median nerve were found across the carpal canal in some
of these patients requires some explanation. The symp-
toms in these patients appeared to arise primarily in the
proximal part of the forearm, where tenderness of the pro-
nator and the nerve proximal to the pronator area was evi-
dent. These symptomscould be worsened more by resisted
pronation and contraction of the flexor digitorum super-
ficialis than by the Phalen test. Mostof this small group of
patients had complaintsof fatigue and pain in the forearm,
with paresthesias in the fingers which usually followed the
onset of the pain, Generally, these patients did not have
nocturnal paresthesias. Three of them had had previous
carpal-tunnel decompressionwithout relief of their pri-
mary symptoms, and two additional patients had not re-
spondedto injection of cortisone into the carpal canal. As
mentioned, there may be a relationship between the pro-
nator teres syndromeand the carpal tunnel syndrome be-
cause of increased susceptibility of the nerve to a com-
pression neuropathy when the syndromes coexist. The
finding of an increased latency in the conduction time of
the median nerve in the carpal tunnel could be explained
in that way.
It is interesting to speculate whyanterior interosseus-
nerve palsy is not seen with the pronator teres syndrome
whenthe sites of the lesions are so near to one another in
the area between the ulnar head of the pronator and. the
origin of the flexor digitorum superficialis. In the seven-
year period of this study, only two such patients with the
Kiloh-Nevinsyndromewere seen in our institution, and in
themdirect pressure of the ulnar head of the pronator teres
muscle was seen on the anterior interosseus nerve just
belowits origin.

References
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