Answer a fun quick question about nerve compressions around the elbow, learn more about what defines this particular nerve compression and find some helpful tips on the best hand therapy treatment.
Answer this Quick Question
Which are potential sites of ulnar nerve compression at the elbow?
- Deep flexor pronator aponeurosis
- Epicondylar groove
- Aponeurotic arcade
- All of the above
Answer: d) All of the above
Ulnar Nerve Compression Defined
- The ulnar nerve comes from the medial cord of the brachial plexus (C8-T1).
- It exits the brachial plexus into the axilla continuing into the medial aspect of the anterior compartment of the upper arm.
- It is a mixed nerve containing both motor and sensory axons. It gives off no branches in the upper arm.
- It proceeds between the medial aspect of the triceps muscle and the brachialis muscle, then passes behind the medial epicondyle at the elbow (Cubital Tunnel).
- It crosses the elbow and enters the forearm between the two heads of Flexor Carpi Ulnaris, then continues down the forearm between FCU and FDP.
- It then continues down the forearm and passes into the hand via Guyon’s canal. In the forearm it only supplies FCU and FDP to the RF and LF.
- It is very important in the hand, as supplies several of the intrinsics, responsible for fine control.
- Lumbricals (III, IV)
- Interossei (Palmar & Dorsal)
- FPB (deep head)
- Add Pollicis
The Ulnar nerve sensory supply is only to the hand.
The main sites of ulnar nerve compression are:
- Arcade of Struthers (a fascial band 8 cm proximal to the medial epicondyle, extending from the medial head of the triceps to the medial intermuscular septum)
- The medial intermuscular septum (from the Arcade of Struthers to the medial epicondyle, dividing the anterior and posterior compartments of the arm)
- The medial epicondyle
- The Cubital tunnel (described below)
- The deep flexor pronator aponeurosis
- Two heads of FCU
- Guyon’s canal/Ulnar canal (described in a separate blog)
Anatomy: The cubital tunnel is a fibro-osseous structure. The roof is the Osbourne ligament (from medial epicondyle to the olecranon). The floor is the Medial Collateral ligament & elbow joint capsule.
- The Cubital tunnel is the most common site of compression of the ulnar nerve around the elbow.
- With elbow movement, there are changes to the shape, space and pressure within the cubital tunnel as well as changes with the ulnar nerve:
- The cubital tunnel is most patent with the elbow in extension.
- With elbow flexion, the tunnel becomes wider, flatter and can narrow by 55%, making the nerve susceptible to compression.
- With elbow flexion, the ulnar nerve itself also undergoes changes, with excursion as much as 10mm of elongation.
- Repetitive movement may cause the nerve to become inflamed. This results in oedema and loss of nerve glide.
- Nerve traction which may be worsened by shoulder abduction and wrist extension.
- As the ulnar nerve sits so superficial at this level, it makes it susceptible to external pressures (e.g. from positioning, or from soft tissue masses such as ganglia, lipomas, cysts, gout or thickened synovium).
A client with Cubital Tunnel Syndrome may present as follows:
Clinical signs and symptoms
- Pain or paraesthesia on the medial aspect of the forearm
- Sensory changes in the ulnar side of the hand, the little finger and the ulnar half of the ring finger
- Often worse at night secondary to position
- Muscle weakness
- Claw deformity
Possible risk factors:
- Remote history of fractures around the elbow
- Fall with direct trauma to the medial elbow
- Habitual positioning of the elbow
- Repetitive elbow flexion
- Systemic Disease
- Recurrent subluxation or dislocation of ulnar nerve
In all of these, a positive test reproduces the tingling / paraesthesia in the ulnar nerve distribution in the hand
Tinels test: percussion along the course of the ulnar nerve, distal to proximal.
Elbow flexion test: full active elbow flexion with forearm supinated, wrist in neutral, sustained for 60 seconds.
Pressure test: Apply external pressure over the cubital tunnel for 60 seconds.
Combined Pressure & Flexion test: Combines maximal elbow flexion and externally applied pressure to the ulnar nerve.
- Clawing of the 4th and 5th fingers
- Wartenburg’s sign: posturing of the little finger in abduction secondary to a weak interosseous muscle
- Froments sign: Patient holds a piece of paper in a lateral pinch between thumb and IF. Therapist pulls the paper and looks at how the patient stabilises. A positive test is characterized by flexion of the IP joint of the thumb (i.e. using FPL rather than AddPoll).
- Jeanne’s sign: As above, but a positive sign is thumb MP hyperextension to compensate for a weak adductor pollicus muscle.
- Interossei testing:
- Finger flexion sign: client holds a piece of paper between his /her fingers while therapist tries to pull it out. Will flex at MPJ to compensate for interossei weakness
- Crossed finger test – inability to cross the MF over the IF.
Hand Therapy for Cubital Tunnel Syndrome
The goal of hand therapy for these clients is to eliminate or decrease the frequency of symptoms and to prevent further progression of the disease. 90% recover with conservative regimens in mild or moderate disease (Eisen and Danon 1974). 88% of patients with mild or moderate symptoms were treated successfully with rigid night splinting and activity modification (Shah et al 2013).
An elbow pad may help to reduce external pressures on the ulnar nerve at the elbow.
- Night splinting stops the client from sleeping with his/her arm fully flexed
- Day / functional Anti Claw Deformity Splint (if there are motor symptoms)
The client should be educated regarding self-management and activity modification, avoiding resting on the elbows, or doing sustained or repetitive elbow flexion activities.
Here are my top 3 hand therapy techniques for Cubital tunnel syndrome
Ulnar nerve gliding exercises. Sometimes nerve gliding exercises are called “sliders” or “flossing”. Whatever you call them, the goal is to get the nerve gliding and sliding as it should up and down and side to side between the adjacent structures and soft tissues. This improves the blood flow to the nerve, reduces oedema and prevents adhesions. Neurodynamics should always be part of your nerve management strategy.
Activity modification advice. If the client understands why you are asking them to do something, understands their condition and rehabilitation expectations, they are much more likely to comply. Self-management and activity modification are KEY to managing cubital tunnel syndrome. My advice is as follows:
- Do not rest your elbow on tables, armrests or other firm surfaces.
- Avoid exercises and activities that require you to bend your elbow repetitively (e.g. biceps curls or push-ups).
- Avoid or minimize activities that require you to keep your elbow in a sustained or repetitive bent position
- Prolonged blow-drying of hair
- Overhead lifting activities
- Driving – adjust the seat position so that your elbows are open and relaxed; avoid resting your arms on the elbow support or window
- Computer work – position the height of the keyboard and mouse so that the elbows are open a bit more than 90 degrees
- Playing the guitar (because of the positioning of the fretting hand); warm-up prior to playing, take frequent breaks, stretch often
3. In-hand manipulation activities. For those clients who have motor symptoms but function is returning, in-hand manipulation activities are a fabulous way to condition and strengthen those tiny intrinsic ulnar nerve innervated muscles. Try moving items from fingertips-to-palm and palm-to-fingertips, use tongs and tweezers to pick up small items, roll two ming balls in your hand, retrieve small items from therapy putty, etc.
You could also try:
Look proximal and distal. Therapists should always clear the neck as part of the initial assessment. Because of the contribution from C8/T1 to the medial cord of the brachial plexus before becoming the ulnar nerve, proximal nerve irritation (e.g. a disc bulge) may have similar symptoms. Often however, if that is the case, the pattern of pain /numbness is along the entire C8 dermatome, rather than only in the ulnar side of the hand. Other potential proximal differential diagnoses include thoracic outlet syndrome, or Pancoast tumour. Medial elbow pain may only be because of medial epicondylitis / golfers elbow (although in that case there should be no sensory or motor neurological symptoms in the hand). Also be aware that the ulnar nerve can be compressed at the wrist, in Guyon’s canal (more about that in a later blog).
Acupuncture - If you have the skill / experience, try using acupuncture either along the SI pathway, or dry needling into muscles that you feel may be resulting in entrapment (e.g. pronator teres) this can be a fabulous adjunct to hand therapy.
Onward referral for surgical opinion. If severe symptoms continue despite all conservative interventions, onward referral may be indicated. For a small minority of cases, surgery may be required.
- Simple Decompression
- Decompression with medial epicondylectomy
- Subcutaneous transposition
- Submuscular transposition
- Intramuscular transposition
My professional favourite for cubital tunnel is: The Cubital Tunnel Splint
We have an excellent range of elbow supports that may be suitable for your clients after cast removal.
What are your tips for treating Cubital tunnel syndrome?
This blog is a discussion format. We have listed our views above but would love to know what you think, what your comments are or how you best treat Cubital Tunnel Syndrome in your practice. Add your comments below in the comments box or feel free to email Alison@handtherapyproducts.com