Cubital Tunnel, Pronator Teres, & Radial Tunnel Syndrome Flashcards
muscles and nerves
Cubital tunnel syndrome = Flexor carpi ulnaris + Ulnar Nerve
Pronator teres syndrome = Pronator teres + Median Nerve
Radial tunnel syndrome = Supinator + Radial Nerve (Posterior Interosseus Nerve)
Cubital Tunnel Syndrome
Characteristics
cubital tunnel is located where the ulnar n. passes between the 2 heads of Flexi carpi ulnaris (FCU); one head blends with flexor tendon attachments at medial epicondyle of humerus; other head originates on medial aspect of olecranon process; tunnel is spanned by an aponeurotic band connecting the two heads; syndrome results when ulnar n. is compressed between two heads of FCU or by the aponeurotic band
during elbow flexion, space within tunnel decreases up to 55% and ulnar n. is pulled taut; subluxation of ulnar n. as elbow flexes can also produce symptoms
acute or chronic compression of elbow; biomechanical factors (excessive cubital valgus) can play a role
can occur due to bone spurs, synovial ganglions, fibrous bands within muscles, mechanical compression during flexion, hypertonicity of FCU
ulnar n. is increasingly sensitive to compression if more proximal nerve compression pathologies exist (double crush phenomenon)
pain, burning, tingling, paresthesia; more men affected
weakness or atrophy are likely (intrinsic hand muscles)
History
Cubital Tunnel Syndrome :
pain
aching, burning sensations
paresthesia in ulnar nerve distribution
weakness, clumsiness in hand, difficulty performing precise movements with thumb and fingers
ask about repetitive or static flexion of elbow
night symptoms if sleeps with elbow flexed
Area of pain and numbness
Cubital Tunnel Syndrome:
Observation
Palpation
Cubital Tunnel Syndrome:
Observation: may be excessive cubital valgus
muscle atrophy in intrinsic hand muscles (adductor pollicis)
Palpation: pressure on cubital tunnel elicits patients symptoms
assess when elbow neutral and full flexion
may feel bone spurs or synovial masses
tenderness /hypertonicity throughout FCU muscle
Range of Motion and Resistance Testing
AROM: symptoms increase with elbow flexion, decrease with extension; may not be felt if elbow brought rapidly into full flexion and immediately returned to neutral; if held in flexion for more than a minute, symptoms usually felt
PROM: as with AROM
MRT: pain not expected; palpating cubital tunnel during wrist flexion exacerbates symptoms; symptoms may occur if flexion is performed while elbow flexed; weakness possible with adduction or flexion of thumb
Special Tests
Cubital Tunnel Syndrome:
Elbow Flexion Test: standing/seated; bring both elbows into full flexion with forearms supinated and wrists hyperextended; bilaterally; if symptoms reproduced within 60 seconds, compression of ulnar n. in cubital tunnel likely; puts tensile stress on ulnar n. while decreasing space within cubital tunnel
Froment’s Sign: patient holds piece of paper between thumb and base of index finger (as if holding a key); therapist tries to pull paper out; positive test if can easily pull paper away; Adductor pollicis may be weak (tests for Guyon’s Canal Syndrome)
Differential Evaluation
Cubital Tunnel Syndrome:
Guyon’s canal syndrome
thoracic outlet syndrome
carpal tunnel syndrome
other regions of ulnar nerve compression or tension
systemic disease,
space-occupying lesions in elbow
ligament damage
cervical radiculopathy
myofascial trigger point referral
diabetic neuropathy
osteophytes
Suggestions for Treatment:
Cubital Tunnel Syndrome:
relieve pressure on affected nerve
eliminate activities that keep elbow flexed for long periods or apply pressure to cubital tunnel
splints for at night to keep elbow extended
surgery
massage to decrease muscular hypertonicity in FCU
deep stripping or active engagement to reduce tension and compression of ulnar n.
caution with direct compression over ulnar nerve at FCU
Pronator Teres Syndrome:
Characteristics
develops from compression of the median n. by Pronator teres muscle; as median n. passes the elbow it runs between 2 heads of Pronator teres where it can be compressed (hypertonicity or fibrous bands); anatomical anomalies (nerve traveling deep to both heads) can be a cause
results from repetitive motions that cause Pronator teres hypertonicity; occupational activities cause overuse of Pronator teres
symptoms felt in the anterior forearm and median n. distribution in the hand; women affected more
pain can radiate proximal or distal to nerve compression
exacerbated by repetitive elbow flexion; symptoms in forearm and hand
atrophy possible in thenar muscles
can be double or multiple crush phenomenon to median n.
fibrous band from Biceps brachii can also compress median n. (connects distal portion of biceps to ulna)
Pronator teres compression may affect anterior interosseous nerve (AIN) instead of median n.
History:
Pronator Teres Syndrome:
aching, shooting or sharp electrical pain
paresthesia in median n. distribution of hand
may be felt in anterior forearm also
pain aggravated when using Pronator teres against resistance
ask about repetitive elbow movements
night pain not usual
Area of pain and numbness
Pronator Teres Syndrome
Observation
Palpation
Observation: may cause atrophy of forearm and hand muscles supplied by median n.
Palpation:
tenderness and hypertonicity in forearm flexors and Pronator teres
symptoms aggravated when palpating Pronator teres
Range of Motion and Resistance Testing
Pronator Teres Syndrome
AROM: rarely causes discomfort unless condition is advanced; slight discomfort at end of supination if wrist hyperextended and elbow extended (stretching of Pronator teres and median n.)
PROM: supination produces pain if wrist hyperextended and elbow extended (stretching of Pronator teres and median n.)
MRT: pain with forearm pronation and possibly with elbow flexion; weakness in flexors of hand/fingers due to impaired motor function of median n.
Special Tests
Pronator Teres Syndrome
Pronator Teres Test: standing with elbow flexed to 90°; therapist places one hand on patient’s elbow for stability and other hand grasps patient’s hand in a handshake; patient holds position as therapist attempts to supinate patient’s forearm (forcing pronator teres contraction); therapist also extends patient’s elbow; if pain reproduced, good chance median nerve compression by pronator teres (elbow should stay relaxed); pronator teres engaged in isometric contraction which increases compression of median nerve; muscle is then forcefully lengthened into extension producing greater potential nerve compression
Pinch Grip Test: patient firmly pinches tips of thumb and index finger together; if patient is unable to do this without hyperextending DIP joint of index finger, anterior interosseous nerve compressed near elbow; innervates flexor digitorum profundus that flexes DIP of index finger; weakness causes patient to be unable to prevent DIP hyperextension
Differential Evaluation
Pronator Teres Syndrome
carpal tunnel syndrome
other median nerve entrapment sites
cervical radiculopathy
thoracic outlet syndrome
tumors or space-occupying lesions of anterior elbow
medial epicondylitis
medial apophysitis
myofascial trigger point referrals
diabetic neuropathy
Suggestions for Treatment
Pronator Teres Syndrome
reduce compression of median nerve
massage directly to pronator teres
static compressions to treat trigger points, deep stripping and pin-and-stretch
stretching to decrease nerve compression
Radial Tunnel Syndrome
Characteristics
aka resistant tennis elbow: causes pain in the same region as tennis elbow but does not improve with standard epicondylitis treatment
compression of a branch (posterior interosseous nerve) of the radial n. that travels through several fibro-osseous tunnels in the elbow region; symptoms are weakness or atrophy; pain or paresthesia in forearm
caused by anatomical relationship between posterior interosseous n. (PIN) and Supinator
Supinator is composed of a superficial head which is more proximal, arises from the lateral epicondyle of the humerus, radial collateral and annular ligaments; deep head originates on the supinator crest and the fossa of the ulna
the PIN runs between the divisions of the Supinator (arcade of Frohse)
in some cases, fibrous bands or hypertonicity from TP pain in the Supinator produce compression of the PIN
can also be compressed by cysts or other soft-tissue masses
pain felt near lateral epicondyle of humerus, can radiate into anterior and lateral forearm
History
Radial Tunnel Syndrome
pain
paresthesia or numbness near lateral epicondyle of humerus
aching, extends distally into anterior/lateral forearm
may radiate proximally
ask about activities of prolonged isometric contractions of forearm muscles
may report weakness when gripping/holding objects
Areas of pain and numbness
Radial Tunnel Syndrome
Observation
Palpation
Radial Tunnel Syndrome
Observation:
no visual characteristics
motor impairment during some movements or positions
may be able to extend wrist but difficult or impossible to fully hyperextend fingers at MCP or finger joints because of weakness
Palpation:
pressure directly on Supinator distal to lateral epicondyle of humerus reproduces pain
can differentiate between lateral epicondylitis due to location
Range of Motion and Resistance Testing
Radial Tunnel Syndrome
AROM: unlikely to be painful; pain may occur at end of full pronation when Supinator is pulled taut against underlying nerve
PROM: as with AROM
MRT: supination may aggravate symptoms and increase pain; preformed with elbow extended to decrease contribution from Biceps brachii; weakness possible in all muscles innervated by the PIN
Special Test
Radial Tunnel Syndrome
Upper Limb Neurodynamic Test #3: not specific for radial tunnel syndrome; helpful to identify various compression or tension pathologies that affect radial nerve
Differential Evaluation
Radial Tunnel Syndrome
lateral epicondylitis
tumors or synovial masses in elbow
ligament sprains in elbow
cervical radiculopathy
thoracic outlet syndrome
myofascial trigger point referrals
other proximal radial nerve lesions
diabetic or other systemic neuropathies
Suggestions for Treatment
Radial Tunnel Syndrome
massage and soft-tissue therapy
address radial n. entrapment in wrist and finger extensors in forearm and Supinator
deep longitudinal stripping to free restrictions in distal region of radial n.
deep broadening techniques for wrist extensors
pin-and-stretch to Supinator to reduce nerve compression near the PIN and arcade of Frohse
