Updated: 6/6/2021

Flexor Pronator Strain

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  • Summary
    • Flexor Pronator Strains are acute or chronic muscle strains of the flexor pronator mass, distal to its origin on the medial epicondyle.
    • Diagnosis is made clinically with medial elbow swelling and ecchymosis in acute strains with
      tenderness distal to the medial epicondyle. MRI studies can be used to help identify complete tears or UCL injuries.
    • Treatment is generally nonoperative with rest, activity modifications and physical therapy. 
  • Epidemiology
    • Demographics
      • golfers
      • cricket players
      • throwing athletes
  • Etiology
    • Pathophysiology
      • acute muscle tear
        • single event of a large, eccentric force during resisted wrist flexion, forearm pronation, and valgus at the elbow
          • chronic overuse can lead to acute flexor pronator rupture
        • sudden onset of pain and flexor weakness
      • chronic tendonitis
        • repetitive elbow valgus, wrist flexion, and forearm pronation
    • Associated conditions
      • ulnar collateral ligament insufficiency
        • should be ruled out in throwing athletes
  • Anatomy
    • Flexor pronator mass provides dynamic support to the medial elbow against valgus stress
    • Flexor pronator mass includes (proximal to distal)
      • Pronator Teres (median n.)
      • Flexor Carpi Radialis (median n.)
      • Palmaris Longus (median n.)
      • FDS (median n.)
      • Flexor Carpi Ulnaris (ulnar n.)
  • Presentation
    • History
      • acute event of hitting the ground during golf, bat, or racquet swing
      • history of throwing or racquet sports
      • repetitive gripping and/or elbow valgus stress activities
    • Symptoms
      • pain
        • medial elbow pain distal to the medial epicondyle
        • chronic pain during late cocking/early acceleration
    • Physical exam
      • medial elbow swelling and ecchymosis in acute strain
      • tenderness distal to medial epicondyle
      • provocative tests
        • pain with elbow extension and resisted wrist flexion or pronation
      • examine for associated conditions
        • negative moving valgus stress test
        • normal neurovascular exam
  • Imaging
    • Radiographs
      • usually normal
    • MRI
      • indications
        • unclear source of medial elbow pain
        • grade severity of muscle strain
        • rule out other causes of medial elbow pain such as UCL rupture
      • findings
        • edema in flexor pronator mass
        • partial tearing or complete rupture of flexor pronator mass
  • Differential
    • Medial epicondylitis
    • UCL injury
    • Valgus extension overload with posteromedial olecranon impingement
  • Treatment
    • Nonoperative
      • NSAIDS, rest, physical therapy, steroid injections
        • indications
          • first line of treatment
        • technique
          • ROM and flexor pronator strengthening x 4-6 weeks
          • corticosteroid injection for chronic flexor pronator tendonitis
            • rarely needed
            • avoid UCL due to risk of rupture
        • outcomes
          • typical resolution and return to sport in 4-6 weeks
    • Operative
      • primary surgical repair
        • indications
          • significant (>2.5 cm) retraction
  • Complications
    • Continued medial elbow pain and valgus instability
      • unrecognized UCL insufficiency
  • Prognosis
    • Typically resolves with 4-6 weeks of activity restriction
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