ICAK Certification Courses Elbow Conditions Pronator Teres syndrome Supinator syndrome Ulnar sulcus syndrome SEE LEAF and WALTHER MANUALS FOR IN DEPTH DISCUSSION ©Zatkin/Stark 2007 Copyright Stark/Zatkin-2007

Pronator Teres Syndrome ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Pronator Teres Syndrome Entrapment of Median nerve between ulnar and radial heads of Pronator Teres muscle most common site of compression caused by muscle hypertrophy or thickening of aponeurotic fascia between two heads of pronator teres Median 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 forearm ©Zatkin/Stark 2007 2 STARK/ZATKIN* 2## Copyright Stark/Zatkin-2007

Pronator Teres Syndrome… There are four reported sites of median nerve compression pronator teres: most common flexor digitorum superficialis arch: second most common, fibrosis of flexor digitorum superficialis arch supracondylar process/ligament of struthers lacertus fibrosis (bicipital aponeurosis)

Lacertus Fibrosis The 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 Syndrome… ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Pronator Teres Syndrome… Symptoms of decreased hand strength, problems with writing, numbness/tingling in hand and especially palm, pain in proximal forearm, fatigue with exercise Signs and symptoms usually worse with activity Nocturnal symptoms seen with carpal tunnel syndrome are typically absent Negative 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 ulna ©Zatkin/Stark 2007 5 STARK/ZATKIN* 5## Copyright Stark/Zatkin-2007

Pronator Teres Syndrome… ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Pronator Teres Syndrome… Weakness of finger flexors (ie: flexor digitorum profundus) Strengthens with approximation of proximal radius and ulna ©Zatkin/Stark 2007 6 STARK/ZATKIN* 6## Copyright Stark/Zatkin-2007

Pronator Teres Syndrome… ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Pronator Teres Syndrome… Challenge radial head and adjust Often superior or lateral Test Pronator teres for proper function Weakness Shortened : SCS/RSCS, FF, etc Test for core muscle dysfunction Esp transverse abdominis ©Zatkin/Stark 2007 7 STARK/ZATKIN* 7## Copyright Stark/Zatkin-2007

Median Nerve Provocative tests Resisted forearm pronation for 30 to 60 seconds demonstrates compression at pronator teres when symptoms are reproduced Resisted elbow flexion and supination of the forearm can localize compression to lacertus fibrosis Resisted 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 radiographs EMG/NCV is inconsistent and diagnosis should be made clinically

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

ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Supinator Syndrome Entrapment of Radial nerve beneath Supinator muscle Symptoms with repetitive forearm motions esp. throwing Decreased hand strength, pain deep in posterior forearm Weakness of extensor carpi ulnaris Strengthens with approximation of proximal radius and ulna or with lower arm in full supination ©Zatkin/Stark 2007 10 STARK/ZATKIN* 10## Copyright Stark/Zatkin-2007

ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Supinator Syndrome… Test Supinator for normal function especially fascial involvement Test for core muscle dysfunction Esp transverse abdominis ©Zatkin/Stark 2007 11 STARK/ZATKIN* 11## Copyright Stark/Zatkin-2007

ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Ulnar Sulcus Syndrome Entrapment of ulnar nerve in ulnar sulcus of medial epicondyle of humerus due to laxity or enlargement of epicondylo-olecranon ligament Symptoms of numbness/tingling and/or pain in ulnar nerve distribution ©Zatkin/Stark 2007 12 STARK/ZATKIN* 12## Copyright Stark/Zatkin-2007

Ulnar Sulcus Syndrome… ICAK Certification Courses ICAK BASIC CERTIFICATION COURSE* Ulnar Sulcus Syndrome… Weakness of flexor carpi ulnaris in elbow flexion but usually not in extension Challenge humerus and ulna and adjust Test ligament for fascial shortening and raw bone supplementation ©Zatkin/Stark 2007 13 STARK/ZATKIN* 13## Copyright Stark/Zatkin-2007