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    Move Forward Guide

    Physical Therapist's Guide to Cubital Tunnel Syndrome

    Cubital tunnel syndrome is the second most common nerve compression occurring in the arm. (Carpal tunnel syndrome is the most common.) It is a condition caused by increased pressure on the ulnar nerve at the elbow. This pressure can result in discomfort and pain, and may progress to loss of function of the hand. Cubital tunnel syndrome generally affects men more than women, especially those with jobs that require repetitive elbow movements and a bent elbow position, such as using tools like drills at work, talking on the phone, doing computer work, painting, or playing an instrument. Physical therapists help people with cubital tunnel syndrome reduce pain and swelling and restore normal movement and function to the arm, wrist, and hand.


     

    What is Cubital Tunnel Syndrome?

    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 a tunnel called the cubital tunnel. Although it is not an actual bone, this area is commonly called your “funny bone.” When you hit the 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.

    Cubital Tunnel-Small

    Cubital Tunnel Syndrome: See More Detail

    Cubital tunnel syndrome often results from prolonged stretching of or pressure on the ulnar nerve. When the arm is bent for a long time, such as when 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 a table and the ulnar nerve is pushed over the bone, which may cause the sensation of tingling, numbness, burning and/or pain along the inside of your arm and hand.

     

    Signs and Symptoms

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

    • Intermittent pain, numbness, and tingling brought on by sustained bending of the elbow
    • Tenderness on the inside of the elbow where the nerve is close to the surface

    Later symptoms sometimes include:

    • Difficulty gripping and holding on to objects
    • Muscle wasting of the small muscles of the hand
    • A hand deformity in which the small and ring fingers bend inward, referred to as an "ulnar claw hand"

    CAUTION: More severe symptoms, especially those with muscle wasting and hand deformities, should be evaluated by a physician.

     

     

    How Is It Diagnosed?

    Cubital tunnel syndrome can be diagnosed by a physical therapist or a physician. Your physical therapist will typically perform a comprehensive evaluation that should include 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 physical therapist may use the following tests and examination:

    • Observation and inspection of the elbow and forearm
    • Touching and moving the arm in the area of the nerve to determine its relationship to the elbow and its stability in the groove behind the elbow where the nerve travels
    • Tapping the nerve at the elbow (the Tinel's sign test)
    • Assessing the flexibility of the ulnar nerve
    • A sensory examination that includes both light touch, a test of the ability to distinguish between sharp or dull stimulus, and the ability to distinguish 1 point from 2 points (2-point discrimination)
    • Checking the strength of specific muscles of your hand
    • Checking your pinching and gripping ability

    Cubital tunnel syndrome can be accurately diagnosed clinically without additional testing. Occasionally you may be referred for electrodiagnostic tests called electromyography (EMG) and/or a nerve conduction study (NCS). These tests evaluate the ability of the nerve to conduct signals along its full length. They can help determine the exact site of the compression and estimate the extent of the compression.

    If your physical therapist considers your symptoms to be more severe, the therapist may refer you to a physician for an additional assessment.

     

    How Can a Physical Therapist Help?

    Many cases of mild to moderate cubital tunnel syndrome can be treated without surgery. Your physical therapist will determine the activities that bring on your symptoms. The recommendations at this point will be to avoid those activities for a time. Remember, the nerve is irritated and at times swollen. If the irritation and swelling can be reduced, the symptoms should resolve.

    In more advanced cases, your physical therapist 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 physical therapist may teach you:

    Range-of-motion exercises. Your physical therapist will show you specific exercises to help return full length to the muscles of the arm that have shortened due to protective posturing, and to maintain the normal length of those that have remained unaffected.

    Muscle strengthening exercises. Improving 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.

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

    If Surgery Is Required

    More severe or prolonged cases of cubical tunnel syndrome may require surgery. The longer you have experienced symptoms and the more you experience weakness, numbness, tingling, and pain the more likely you are to need surgery. The goal of surgery is to relieve the pressure on the ulnar nerve.

    Your physical therapist will design an individual program of postsurgical physical therapy based on the nature of your operation and the surgeon’s instructions. Each surgery will require a unique treatment regimen, but your postsurgical rehabilitation will involve many of the elements discussed above. Activity modification will be a big part of your postsurgical rehabilitation to prevent recurrence of your symptoms.

     

    Can this Injury or Condition be Prevented?

    Little is known about prevention of cubital tunnel syndrome. Often, the syndrome is not diagnosed until symptoms are already present. However, some general precautions may be taken.

    • Obesity has been linked by some researchers to cubital tunnel syndrome. Healthy lifestyle choices and a reduction in your weight may help prevent its development.
    • People in occupations that require holding the elbow in a bent position, such as computer programmers, should be encouraged to perform consistent positional changes to take stress off the ulnar nerve.
    • Diabetes has been recognized as a risk factor.
    • Knowledge of how to avoid positions and activities that can cause ulnar nerve irritation may help prevent injury. Modifications to daily activities such as avoiding positioning the elbow in a bent position for a prolonged period of time, and not resting the elbow on hard surfaces can help. At work, finding ways to limit repetitive motions and the use of vibratory tools (such as drills) may decrease risk.

    Your physical therapist will teach you movement and lifestyle modifications to help prevent recurrence of cubital tunnel syndrome once it has been diagnosed.

     

    Real Life Experiences

    Cara is a 45-year-old nursing-home administrator who spends hours at her desk talking on the phone and writing up reports. Recently, Cara has begun to feel intermittent pain in her elbow, and numbness and tingling down the inside of her hand and forearm. Initially, she noticed her pain while talking on the phone. Cara’s pain would come and go, but she could change her arm position to reduce it. Over the past month, however, she has felt constant pain in her elbow and has had difficulty gripping her tennis racquet; she feels her tennis game has suffered as a result. Cara's tennis pro suggests she see a physical therapist.

    After a thorough evaluation, Cara’s physical therapist tells her she is suffering from a mild-to-moderate case of cubital tunnel syndrome. He recommends conservative treatment. They begin with light stretching exercises, which include nerve gliding to maintain the flexibility and motion of the ulnar nerve when the arm is bent. Cara is given a splint that keeps her elbow slightly bent. This position takes pressure off the nerve. Her physical therapist advises her to wear the sling at work, to limit the use of that arm at work, and to no longer lean her arms on her desk.

    Over the next few weeks, Cara learns new movement and muscle strengthening exercises in addition to her gentle nerve gliding exercises. She wears her splint daily. Cara’s physical therapist teaches her new ways to position herself at her desk, and to correct her posture throughout the day.

    After 4 weeks of treatment, Cara no longer needs to wear the splint. With her physical therapist’s guidance, and her newly learned ways to position herself at her desk and even at home when cooking or doing housework, she slowly returns to her normal activity levels. She now uses a headset for speaking on the phone at work.

    After 8 weeks, Cara is back playing tennis and, with her new-found grip strength and great new overall fitness level, she hits a return that wins the mixed-doubles final!

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat cubital tunnel syndrome. However, you may want to consider:

    • A physical therapist who has treated people with cubital tunnel syndrome. Some physical therapists have a practice with a focus on the elbow, wrist, and hand.
    • A physical therapist who is a board-certified orthopedic clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
    • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in hand therapy (a certified hand therapist [CHT]). This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

    You can find physical therapists with these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people experiencing cubital tunnel syndrome.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of cubital tunnel syndrome. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    American Society for Surgery of the Hand. Cubital tunnel syndrome. Accessed December 14, 2017.

    American Academy of Orthopaedic Surgeons. Accessed January 3, 2018.

    Assmus H, Antoniadis G, Bischoff C, et al. Cubital tunnel syndrome: a review and management guidelines. Cent Eur Neurosurg. 2011;72:90–98. Article Summary on PubMed.

    Palmer BA, Hughes TB. Cubital tunnel syndrome. J Hand Surg Am. 2010;35:153–163. Article Summary on PubMed.

    Svernlov B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur Vol. 2009;34:201–207. Article Summary on PubMed.

    Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Curr Orthop Pract. 2008;19:470–474. Article Summary.

    Lund AT, Amadio PC. Treatment of cubital tunnel syndrome: perspectives for the therapist. J Hand Ther. 2006;19:170–178. Article Summary on PubMed.

    Robertson C, Saratsiotis J. A review of compressive ulnar neuropathy at the elbow. J Manipulative Physiol Ther. 2005;28:345. Article Summary on PubMed.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

    Authored by Christopher Bise, PT, DPT, MS. Reviewed by the MoveForwardPT.com editorial board.

     

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

    Authored by Christopher Bise, PT, MS, DPT. Reviewed by the MoveForwardPT.com editorial board.

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