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Pronator Teres Myotendinous Tear A Case Report & Literature Review Pronator Teres Myotendinous Tear Usama Qayyum, MBBS, Diego Villacis, MD, and Charles M. Jobin, MD The oblique orientation of the Abstract muscle belly allows it to serve Take-Home Points Pronator teres muscle strain is a rare in its primary rotatory role as the ◾ Pronator teres muscle sporting injury reported thus far only in main pronator of the forearm. In- injuries are rare. cricket and golf players. The injury ap- juries to the soft tissue of the me- ◾ Injury can be mistak- dial forearm are common in both pears to occur when the sporting club or en for MUCL injury in racket strikes the ground during a forceful elite and recreational athletes, es- athletes. pecially in racket and club sports.3 swing and causes the elbow to experi- ◾ Tenderness and weak/ ence an eccentric force during resisted Often, these injuries are related to painful forearm pronation elbow flexion and pronation. On initial overuse and chronic fatigue of the are common findings. surrounding soft tissue—caused presentation, this injury can be mistaken ◾ MRI confirms the diagno- for injury to the medial ulnar collater- by repetitive flexing, gripping, or sis and helps grade the al ligament, or exacerbation of medial swinging. Even when identified muscle strain injury. epicondylitis. On examination, bruising early, these injuries can result in ◾ Conservative treatment is 4 and tenderness distal to the elbow over a significant loss of training time. recommended and prog- the course of the pronator teres are often In this article, we report a case nosis is excellent even for present. Advanced imaging confirms the of pronator teres muscle tear at high-grade strains. diagnosis and can help in grading injury the myotendinous junction. The severity. In this article, we report the case patient provided written informed consent for print and electronic publication of this of a patient who was conservatively treat- case report. ed, and returned to function and sport by 6 weeks after a period of rest and restrict- Case Report ed activities. The prognosis is excellent for A right-hand–dominant 36-year-old man presented even high-grade strains. Complete return to the clinic with pain on the medial side of his to sporting function without residual weakness is expected. ronator teres muscle strain is a rare sporting injury reported only in cricket players, and P now in a golfer whose forearm experienced an eccentric force during resisted elbow flexion and pronation.1,2 The injury occurs when the sporting club or racket strikes the ground during a swing, impeding forward progress and subjecting the pronator teres muscle to eccentric forces in excess of what it can withstand. The pronator teres, one of several muscles that comprise the flexor wad of the forearm, consists of 2 heads, originating proximally from the medical epicondyle and attaching distally to the shaft of the radius on Figure 1. Medial elbow with non-gravity-dependent ecchymosis over course of pronator its lateral surface and just distal to the supinator. teres muscle, 3 days after injury. Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com March/April 2017 The American Journal of Orthopedics ® E105 Pronator Teres Myotendinous Tear A B C Figure 2. (A) Coronal T2-weighted magnetic resonance imaging (MRI) shows isolated edema of pronator teres and partial tearing of muscle belly near the myotendinous junction. (B) Axial T2-weighted MRI of proximal forearm shows edema of pronator teres muscle belly and fluid around the myotendinous zone of injury. (C) Sagittal T2-weighted MRI of the pronator teres injury. right elbow after sustaining an injury to the elbow triceps were uninjured. while playing golf several days earlier. The patient, The patient was instructed to rest the elbow an advertising executive, was playing recreational from strenuous activity, golf in particular, for 4 golf several times a month and had no significant weeks. Physical therapy for ROM and forearm medical history or previous symptoms related to strengthening of the surrounding flexor wad was the elbow. Initial pain symptoms began during a initiated at 2 weeks and continued for 4 weeks. second round of play, immediately after the patient The patient was advised to take over-the-counter miss-hit an iron shot, making contact mostly with nonsteroidal anti-inflammatory drugs as needed for the ground and causing the club to forcefully stop. comfort. On repeat examination at 4 weeks, with The pain was on the medial side of the elbow and tenderness or weakness with pronation absent forearm. The patient noted progressive swelling and full ROM regained, the patient was released and bruising at the pain site and development of back to full activity. He was able to return to golf forearm weakness. Physical examination during and reported being symptom-free and having no the clinic presentation revealed ecchymosis on the sense of weakness or loss of control. anterior medial forearm, medial elbow, and medial triceps (Figure 1). Mild tenderness to palpation Discussion was elicited over the medial elbow, specifically over A tear of the pronator teres is an exceedingly rare the course of the flexor pronator mass. When the injury. Our results with conservative treatment elbow was assessed for tender areas, the medial and a full return to previous activity level are epicondyle was not tender. Range of motion (ROM) consistent with the only other case reported in the testing revealed 120° of flexion and 10° short of full literature.5 In contrast to our patient, the previous extension, attributed to swelling from acute injury. patient sustained a tear of the pronator teres after The patient had full supination and pronation, but a prolonged period of batting during a recreational the pain was reproduced with either movement. cricket match. The pain produced weakness with flexion and pro- Our patient’s pronator teres injury occurred nation. Valgus stress test results were normal; there at the myotendinous junction, a muscle-tendon was no re-creation of symptoms. The median nerve transition zone often susceptible to injury. What is was negative for the Tinel sign, and the rest of the unusual for this athletic medial elbow injury is that neurovascular examination was unremarkable. The the patient reported no previous symptoms, and ipsilateral shoulder was normal on examination. it appears that, though the surrounding muscle Noncontrast magnetic resonance imaging (MRI) may have been fatigued by overuse from the round showed a high-grade partial tear of the pronator of golf earlier that day, the pathology was caused teres myotendinous junction (Figures 2A-2C). In by an acute eccentric force. During a golf swing, the surrounding tissue there was an associated tremendous forces are put on the entire body, increased signal representing edema. Also found from the lower extremities to the forearm and the was a small intramuscular hematoma. The median fingers. Successful completion of the transfer of nerve, medial collateral ligament, distal biceps, and energy from the golf club to the ball requires both E106 The American Journal of Orthopedics ® March/April 2017 www.amjorthopedics.com U. Qayyum et al proper technique and proper functioning of key occur when the sporting club or racket strikes the muscles. Specifically, parameters such as ball po- ground during a forceful swing impeding forward sitioning, club angle, and wrist control play a major progress of the arm. The injury can be confused role.6 Altered forearm positioning or swing arc can with a MUCL injury, or exacerbation of medial significantly affect club head velocity and energy epicondylitis. Physical examination reveals bruising transfer without putting more stress on the golfer.7 and tenderness over the course of the pronator Therefore, it is easy to understand how prolonged teres, often distal to the elbow. Advanced imaging or extended play may fatigue the surrounding confirms the diagnosis and helps grade the sever- elbow muscles, leading to altered technique and ity of muscle strain. Treatment is often conserva- increased susceptibility to acute injury. Biomechan- tive, with return to function and sport after 4 to 6 ical analysis of shoulder motion can provide a help- weeks of rest and restricted activities. The patient ful baseline for assessing injury-related changes in this case report had complete return to sporting in golf swing and developing specific exercise and function, with no residual weakness or pain. rehabilitation programs.8,9 Although injury to the pronator teres is rare, sport physicians should be aware that, after a val- Dr. Qayyum is a Research Fellow, Columbia University De- gus stress or force, bruising and swelling along the partment of Orthopedics, New York, New York. Dr. Villacis is a Clinician Educator, Orthopedic Surgeon, NorthShore medial elbow do not always indicate a medial ulnar University Health System, a teaching affiliate of The Uni- collateral ligament (MUCL) tear or medial epicon- versity of Chicago Pritzker School of Medicine, Glenview, dylitis. The key examination findings that differen- Illinois. Dr. Jobin is Assistant Professor of Orthopaedic tiate this injury from a MUCL injury are the exact Surgery and Residency Program Director, Department of location of pain, the milking maneuver for MUCL Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, New York. incompetence, and the extensive bruising over the muscle course of the pronator teres. MRI plays a Address correspondence to: Charles M. Jobin, MD, Department of Orthopaedic Surgery, New York Presbyte- pivotal role in proper diagnosis.4 In addition, MRI rian/Columbia University Medical Center, 622 W 168th St, allows for evaluation of any concomitant injuries New York, NY 10032 (tel, 212-305-6445; fax, 212-305- that may be obscuring the clinical presentation. 4040; email, [email protected]).
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