Cubital Tunnel Syndrome

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The elbow is a hinge joint between the upper arm bone, the humerus, and the lower arm bones, the radius, and the ulna. The ulna is on the inside of the elbow. The elbow functions similar to a hinge; bending and straightening. There is a nerve that runs on the inside of the elbow (the ulnar side) which is called the ulnar nerve. The ulnar nerve travels behind the axis of the hinge of the elbow and is thus stretched and compressed with bending and straightening of the elbow. The ulnar nerve runs through a tight tunnel formed by a bone, ligament, and tendon called the cubital tunnel. This nerve provides skin sensation to the small finger and ring finger. This nerve also powers nearly all of the muscles within the hand. This nerve travels directly beneath the skin at the elbow and is often referred to as the funny bone.

Cubital tunnel syndrome is caused by compression of the ulnar nerve when it passes under a bony bump (the medial epicondyle) on the inside portion of the elbow. In this area, the nerve is relatively unprotected and can be trapped between the bone and the skin in the cubital tunnel. When you hit your funny bone just the right way, you have actually hit the ulnar nerve; this contact sends a sensation of tingling, numbness, burning, and or pain along the inside of your arm and down to the ring and little fingers. When the ulnar nerve is compressed, it causes the same type of symptoms. The ulnar nerve can be pinched at any point along its length, but the most common site of compression is on the cubital tunnel.

Causes & Symptoms

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Cubital tunnel syndrome often results from prolonged stretching or pressure on the ulnar nerve. When the arm is bent for a long time (such as holding the phone) it stretches the ulnar nerve across the inside of the elbow, creating a traction force that decreases the blood flow to the nerve and may cause nerve irritation. Prolonged pressure on the nerve may happen, for example, when the elbow and lower arm lean against the table and the ulnar nerve is pushed over the bone, which may cause the sensation of tingling, numbness, burning, and pain along the inside of your arm and hand.

Generally, the ulnar nerve provides sensation to the little finger and half of the ring finger. It supplies several muscles in the forearm, but most importantly it controls several of the small muscles in the hand responsible for coordinating finger motion and pinch. Patients with cubital tunnel syndrome commonly exhibit symptoms of intermittent numbness or tingling in the ring and little fingers of the affected extremity, and eventually weakness and loss of fine manipulative hand coordination.

These symptoms may occur with prolonged flexion of the elbow or putting resting pressure against the elbow where the nerve passes. There may be an associated aching discomfort along the inner forearm or elbow. If micro-circulation of the nerve is compromised by prolonged traction or compression, there can be permanent loss of sensation in the ring and little fingers, and eventually, there is loss of pinch and grip strength.

Cubital tunnel syndrome can also occur after a traumatic incident, such as an elbow fracture, or develop slowly over time. It typically begins with numbness and tingling or burning on the inside of the forearm extending down into the hand.

Who Gets Cubital Tunnel Syndrome?

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Cubital tunnel syndrome can occur in people who hold their elbow bent more than 90 degrees for long periods of time. Bending your elbow repeatedly, sleeping with your elbow bent, or prolonged leaning on your elbow can also cause this condition. Furthermore, patients who have fractured or dislocated their elbow or who have bone spurs or swelling in the elbow are at an increased risk of cubital tunnel syndrome. Cubital tunnel syndrome can also be caused by joint damage from arthritis. However, cubital tunnel syndrome is a very late occurrence in the course of arthritis, which is uncommon at the elbow. Another risk factor that is highly associated with this condition is diabetes.

How Does it Affect You? How Serious is it?

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Tapping over the ulnar nerve at the cubital tunnel can produce electric shocks radiating into the ring and little fingers. Bending the elbow may reproduce the aching discomfort about the elbow and forearm or tingling in the fingers.

Therefore, there may be difficulty crossing the middle finger over the index finger. Severe cases will reveal loss of muscle bulk, or wasting, over the little finger aspect of the palm and along the back of the first web space between the thumb and index finger. Other severe conditions resembling cubital tunnel syndrome include compression of the nerves in the neck and shoulder area or compression of the ulnar nerve at the wrist.

If a patient living with cubital tunnel syndrome begins to experience severe symptoms, he or she may be required to undergo a surgery known as a cubital tunnel release. The procedure for this type of surgery is usually carried out as an outpatient in an ambulatory care setting. General anesthesia or local anesthesia supplemented with neuroleptic analgesia may be used throughout this procedure.

This surgery can be painful to most patients; therefore, it is expected that you will require narcotic pain medication for the first couple of days after surgery. The majority of patients suffer no complications following cubital tunnel surgery, however, complications can occur following elbow surgery and include the following:

 

  • Infection

 

  • Elbow instability.

 

  • Nerve damage causing permanent numbness around the elbow or forearm.

 

  • Elbow flexion contracture.

 

  • Pain at the site of the scar.

 

  • Symptoms that were unresolved even after the surgery.

Recommended Treatment & Rehabilitation

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Cubital tunnel syndrome can be diagnosed by a physiotherapist or a physician. Your physiotherapist will typically perform an evaluation that should include an assessment of your neck to rule out compression of the nerve where it starts in the neck. To confirm the compression of the ulnar nerve is occurring at the elbow, your physiotherapist may use the following tests and examinations below:

 

  • Touching and moving the arm in the area of the nerve to help determine its relationship to the elbow, and its stability in the groove behind the elbow where the nerve travels.

 

  • Observation of the elbow and forearm.

 

  • Tapping the nerve at the elbow (also known as the Tinel’s sign test).

 

  • A sensory examination that includes both light touches, a test of the ability to distinguish between sharp or dull stimuli.

 

  • Assessing the flexibility of the ulnar nerve.

 

  • Checking your pinching and gripping ability.

 

  • Checking the strength of specific muscles of your hand.

 

In addition to a completing a physical exam, diagnostic tests for cubital tunnel syndrome may also include:

 

  • Nerve conduction test – This is a test to find out how fast signals travel down a nerve to find a compression or constriction of the nerve.

 

  • Electromyogram (EMG) – This test checks nerve and muscle function and may be used to test the forearm muscles controlled by the ulnar nerve. If the muscles do not work the way they should, it may be a sign that there is a problem with the ulnar nerve.

 

  • X-ray – This is done to look at the bones of the elbow and see if you have arthritis or bone spurs in your elbow.

 

Many cases of mild to moderate cubital tunnel syndrome can be treated without surgery. Therefore, your physiotherapist will be able to determine the activities that bring on your symptoms. In most advanced cases, your physiotherapist will modify your activity and may recommend you use a splint to take the pressure off the nerve. As your condition begins to improve, your physiotherapist may teach you the following:

 

  • Muscle-strengthening exercises – Improving your strength in the surrounding muscles can help reduce pain and improve functional ability.

 

  • Nerve gliding exercises – Nerves have the ability to be stretched, just like muscles or joints. Nerve tissue is the strongest, longest tissue in the body and the one most sensitive to stretching. In cubital tunnel syndrome, the nerve can become tight or trapped; these exercises are an effective means of promoting blood flow to the ulnar nerve and gently stretching it.

 

  • Range-of-motion exercises – Your physiotherapist will show you specific exercises to help return full length to the muscles of the arm that have been shortened due to protective posturing and to maintain the regular length of those that have remained unaffected.

 

  • Ergonomic training – Your physiotherapist will teach you various ways to avoid positions and postures that compress or put a prolonged stretch on the ulnar nerves. You may need to learn how to modify work and self-care activities to prevent further nerve irritation.

 

Certain exercises, like nerve gliding exercises for the arm and hand, can also help decrease pain associated with cubital tunnel syndrome. The following exercises include:

 

Elbow flexion and wrist extension

First, sit tall and reach the affected arm out to the side, level with your shoulder, with the hand facing the floor. Then, flex your hand and pull your fingers up toward the ceiling. Bend your arm and bring your hand towards your shoulder. Repeat this method 5 times a day at a slow pace.

 

Arm flexion

Sit tall and reach the affected arm straight out in front of you with your elbow straight and arm level with your shoulder. Extend your hand away from you, pointing your fingers toward the ground. Finally, bend your elbow and bring your wrist toward your face. Repeat this exercise 5-10 times a day.

 

Head tilt

Sit tall and reach the affected arm out to the side with elbow straight and arm level with your shoulder. Afterward, turn your hand up toward the ceiling. Tilt your head away from your hand until you feel a stretch. To increase the stretch, extend your fingers toward the floor. Lastly, return to starting position and repeat this method 5 times a day.

 

The “A-OK” exercise

Begin by sitting tall and reaching the affected arm out to the side, with your elbow straight and arm level with your shoulder. Next, turn your hand up toward the ceiling. Touch your thumb to your first finger to make the “OK” sign. Bend your elbow and bring your hand toward your face, wrapping your fingers around your ear and jaw, placing your thumb and first finger over your eye like a mask. Hold for 3 seconds, then return to starting position and repeat this exercise 5 times a day.

Alternative & Homeopathic Treatment

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You can try some home remedies by which your uncomfortable sensation and weakness can be eradicated to some extent. Some of these homeopathic treatments that can help reduce cubital tunnel pain are:

 

  • Wrist splints – Keeping your wrist straight will relieve the pressure on your median nerves. As the pain mostly occurs at night, it is recommended to wear the splint in the evening. As a result, you will get relief from the symptoms before they reoccur.

 

  • Avoid putting more pressure – If you’re doing any of the forcing tasks such as writing or typing, relax your grip between your work. This can help reduce the force you are putting in during your daily work activities. You can use an additional soft-grip pen to relax your hand while writing.

 

  • Hand warmers – Keeping your hand warm will help to eradicate the pain and stiffness. After a carpal treatment surgery, doctors will suggest using fingerless gloves and hand-warmers. You can purchase hand warmers over the counter.

 

  • Non-steroidal anti-inflammatory drugs (NSAIDs) – There are some anti-inflammatory medications like aspirin and ibuprofen, which are beneficial for pain relievers. These will also reduce inflammation.