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CUBITAL TUNNEL SYNDROME

Introduction The ulnar nerve is one of the three main nerves in your arm. It travels from your neck, across the inside of your elbow, to your hand, and it can be constricted in several places along the way. The most common place for compression of the nerve is behind the inside part of the elbow. Ulnar nerve compression at the elbow is called cubital tunnel syndrome. Where is the cubital tunnel? The cubital tunnel is a shallow short passageway between the bones and tissues on the inside of the elbow (this area is sometimes called the ‘funny bone’). Due to its narrow opening, it can be easily injured or compressed through repetitive activities or trauma; this results in numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand.

Where causes it? The causes include: • Pressure: Because the nerve has little padding over it, direct pressure on the nerve such as habits of leaning on your elbows for long periods of time can irritate and damage it. • Trauma: a direct blow to inside of the elbow may cause symptoms. • Stretching: keeping the elbow bent for a long time can stretch the nerve behind the elbow. This can happen during sleep or holding a phone for a long period. • Anatomy: sometimes, the ulnar nerve does not stay in its place and snaps back and forth over a bony bump as the elbow is moved. Repeated snapping (termed ‘subluxation’) can irritate the nerve. Sometimes, the soft tissues over the nerve become thicker or there is an “extra” muscle over the nerve that can keep it from working correctly.

What are the symptoms? Cubital tunnel syndrome can cause pain, loss of sensation, tingling and/or weakness. “Pins and needles” usually are felt in the ring and small fingers. These symptoms are often felt when the elbow is bent for a long period of time, such as while holding a phone or while sleeping. Some people feel weak or clumsy.

How is it diagnosed? Area of tingling/numbness Your symptoms and an examination are usually enough to reach the diagnosis. You Typical area of pain with cubital tunnel syndrome might also be tested you for other medical problems like diabetes or thyroid disease. In most cases nerve conduction studies are also performed to measure how well the ulnar nerve is working and to help specify the site of compression (neck, elbow or wrist).

ëBMI Three Shires Hospital, Northampton ëRamsay Woodland Hospital, Kettering ëBMI Saxon Clinic, Milton Keynes ) 01604 633730 8 [email protected] : www.upperlimb.co.uk 2

CUBITAL TUNNEL SYNDROME

What is a Nerve Conduction Study? This is a test on the nerves in the arms & hands. It is a test that measures how quickly messages are travelling along your nerves. The speed at which the nerves are working can give information about whether a nerve is trapped or damaged. The studies are performed by passing small electrical currents through the skin and making recordings of the natural electrical signals further down the nerve or over a muscle. The electrical signals produce a pulsing, tingling sensation, which can be uncomfortable but should not be painful. Some of the pulses will make your muscle briefly twitch. These tests take around 20-30 minutes. There are no after effects and you will be able to go home or to work following the test.

What is the treatment? Non-operative treatment The first treatment is to avoid actions that cause symptoms. Wrapping a pillow or towel loosely around the elbow or wearing a splint at night to keep the elbow from bending can help. Avoiding leaning on the “funny bone” can also help. A therapist can help you find ways to avoid pressure on the nerve, and certain exercises like nerve gliding exercises (‘flossing’) – see below - for the arm and hand can also help decrease pain associated with cubital tunnel syndrome. These exercises will need to be repeated at least once a day, three to five times per week (or as tolerated). Surgery Sometimes, surgery may be needed to relieve the pressure on the nerve - this involves releasing the nerve, moving the nerve to the front of the elbow (transposition), and/or removing a part of the bone. With a transposition the ulnar nerve is carefully moved from behind the medial epicondyle to a new position in front of this bony bump. I prefer to reroute the nerve over the muscles of the forearm but it can also be routed through or under the muscles. The new placement will prevent the nerve from being compressed against the medial epicondyle when the elbow is bent.

What is the likely outcome? Numbness and tingling may improve quickly or slowly. It may take many months for recovery after surgery. Cubital tunnel symptoms may not totally go away after surgery, especially if symptoms are severe.

What happens if it goes untreated? If left untreated, ulnar nerve entrapment will lead to muscle wasting along the forearm and in the hands. This is part of what contributes to the loss of fine motor control. However, it could lead to permanent contraction of the joints in the forearm, elbow, wrists, or hands.

ëBMI Three Shires Hospital, Northampton ëRamsay Woodland Hospital, Kettering ëBMI Saxon Clinic, Milton Keynes ) 01604 633730 8 [email protected] : www.upperlimb.co.uk 3

CUBITAL TUNNEL SYNDROME

Nerve gliding exercises These nerve gliding exercises (sometimes called ‘flossing’) can help decrease symptoms associated with cubital tunnel syndrome. 1. Elbow Flexion & Wrist Extension i. Sit tall and reach the affected arm out to the side, level with your shoulder, with the hand facing the floor. ii. Flex your hand and pull your fingers up toward the ceiling. iii. Bend your arm and bring your hand toward your shoulders. iv. Repeat slowly 5 times.

2. Head Tilt i. Sit tall and reach the affected arm out to the side with elbow straight and arm level with your shoulder. ii. Turn your hand up toward the ceiling. iii. Tilt your head away from your hand until you feel a stretch. iv. To increase the stretch, extend your fingers toward the floor. v. Return to starting position and repeat slowly 5 times.

3. Arm Flexion in Front of Body i. Sit tall and reach the affected arm straight out in front of you with your elbow straight and arm level with your shoulder. ii. Extend your hand away from you, pointing your fingers toward the ground. iii. Bend your elbow and bring your wrist toward your face. iv. Repeat slowly 5-10 times.

4. Doing the “OK” sign i. Sit tall and reach the affected arm out to the side, with elbow straight and arm level with your shoulder. ii. Turn your hand up toward the ceiling. iii. Touch your thumb to your first finger to make the “OK” sign. iv. 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. v. Hold for 3 seconds, then return to starting position and repeat 5 times.

ëBMI Three Shires Hospital, Northampton ëRamsay Woodland Hospital, Kettering ëBMI Saxon Clinic, Milton Keynes ) 01604 633730 8 [email protected] : www.upperlimb.co.uk