Pronator Syndrome: Illness or Disease?

If you have ever experienced the aching forearm pain caused by pronator syndrome, then it's likely you believe this condition to be a real and true problem. But some experts in the orthopedic world aren't convinced.

Pronator syndrome is a nerve entrapment (pressure on the median nerve in the forearm). The median nerve traveling down the inside of the forearm can get pinched between two other soft tissue structures such as muscles, tendons, ligaments, or fascia (connective tissue).

The syndrome produces more than just forearm aching pain. Some patients also report numbness and tingling in the thumb and index finger. The symptoms are usually mild-to-moderate in intensity. Hand function may be impaired but disability from this problem is rare.

There are no tests to really confirm the diagnosis. Electrodiagnostic tests are typically used to confirm other nerve compression problems. The test provides positive proof when there's a problem. But in the case of pronator syndrome, stimulating the nerve with an electrical impulse shows there's a problem in nerve conduction for only one out of every 10 patients with symptoms of pronator syndrome.

Likewise, any of the other clinical tests performed by the surgeon (e.g., pronator compression test, pronation resistance, resisted elbow flexion, resisted motion of the middle finger) have inconsistent results at best.

Women in their 40s are the ones most likely to be seen with this condition. And because there are no objective measures and because surgery to decompress the nerve isn't successful, there is a belief that what we are facing here isn't a disease, but rather an illness.

When surgery does relieve the problem, it could be a placebo effect. So determining disease (true pathologic anatomy or physiology) from illness (physical symptoms caused by emotional or psychologic distress) can't be cleared up by successful treatment.

Until the concept of pronator syndrome can be fully explored and explained, treatment will likely remain nonsurgical. Antiinflammatory medications and a few sessions with a hand therapist may be all that's needed. The therapist will teach the patient how to modify activities to avoid contracting the pronator muscle and thereby keep pressure off the nerve.

Exercises to stretch the nerve and manual therapy to release fibrous tissue around the nerve may help. Any postural effects will be addressed. The therapist may conduct a review of the patient's home and/or office work areas for possible contributing or aggravating factors.

Whether you believe the pronator syndrome exists or not, people affected by this condition are experiencing real symptoms. Future research is needed to get to the bottom of the problem -- in other words, what's really happening here and why, as well as what can be done about it?

For now in the opinion of hand experts, surgery is only recommended on rare occasions and then only after at least six months of nonoperative care first. Other supportive measures may include splinting, acupuncture, or pain medications.

Reference: Steven Presciutti, MD, and Craig M. Rodner, MD. Pronator Syndrome. In The Journal of Hand Surgery. May 2011. Vol. 36A. No. 5. Pp. 907-909.

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