Cubital Tunnel Syndrome: Difference between revisions

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<div class="noeditbox">Welcome to [[Texas State University Evidence-based Practice Project|Texas State University's Evidence-based Practice project space]]. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
'''Original Editors '''  
'''Original Editor '''- [[User:Adam West|Adam West]],  [[User:Fitim Camaj|Fitim Camaj]]


'''Lead Editors''' - Lindsey Katt, Matt Malone, Greg Propst, Zane Richardson
'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]
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== Search Strategy  ==
== Search Strategy  ==


'''Databases''': CINAHL, Cochrane, Medline with Full Text, PubMed, ScienceDirect, GoogleScholar, EBSCO, ProQuest
add text here related to databases searched, keywords, and search timeline <br>


'''Search Terms''': cubital tunnel syndrome, ulnar nerve entrapment, compression, medial elbow pain, ulnar elbow pain, nerve entrapment, ulnar nerve, surgery, conservative treatment, rehabilitation, compression injury of upper extremity, coppieters, anterior transposition of ulnar nerve, ulnar nerve decompression, tardy ulnar neuritis, ulnar nerve glide, osborne, neurodynamics
== Definition/Description  ==


'''Search Timeline''': September 19, 2010 – November 22, 2010<br><br>
Cubital tunnel syndrome is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow.


== Definition/Description<br> ==
== Clinically Relevant Anatomy ==


[[Image:Cubital Tunnel Syndrome Definition.jpg|frame|left|Anatomy of Cubital Tunnel]]Cubital tunnel syndrome (CBTS) is a progressive entrapment neuropathy of the ulnar nerve at the medial&nbsp;aspect of the elbow. The ulnar nerve, which is a motor and sensory nerve, is formed from the medial cord of the brachial plexus, which originates from nerve roots C8 and T1.<ref name="Feindel">Feindel W, Stratford J. Cubital tunnel compression in tardy ulnar nerve palsy. Can Med Assoc J. 1958;78:351.</ref><ref name="Osborne">Osborne GV. The surgical treatment of tardy ulnar neuritis. J Bone Joint Surg Br. 1957;39B:782.</ref><ref name="Tetro">Tetro AM, Pichora DR. Cubital tunnel syndrome and the painful upper extremity. Hand Clin. 1996;12(4):665-677.</ref> The ulnar nerve travels down the posterior aspect of the arm to eventually traverse posterior to the medial epicondyle through an area known as the cubital tunnel. The cubital tunnel extends from the medial epicondyle of the humerus to the olecranon process of the ulna.<ref name="Wheeless">Wheeless CR. Cubital tunnel syndrome. http://www.wheelessonline.com/ortho/cubital_tunnel_syndrome. Updated June 5, 2010. Accessed November 1, 2010.</ref> The nerve runs superficial to the ulnar collateral ligament (UCL) and deep to the aponeurotic attachment of the flexor carpi ulnaris (FCU), which is also known as Osborne’s ligament. Once the ulnar nerve reaches the proximal border of Osborne’s ligament it is located in the cubital tunnel.
The ulnar nerve is comprised of nerve roots&nbsp;C8 and T1.&nbsp;The ulnar nerve can become compressed withiin the cubital tunnel at multiple levels including: the arcade of Struthers, the medial intermuscular septum, the medial epicondyle, Osborn's ligament at the cubital tunnel and the flexor-pronator aponeurosis.<ref name="Husain">Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Current Orthopaedic Practice: 2008;19(5):470-474.</ref><br>


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


Cubital tunnel syndrome is the second most commonly reported upper extremity entrapment neuropathy and is the most common ulnar nerve neuropathy.<ref name="Coppieters">Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating nerve-gliding techniques in the conservative treatment of cubital tunnel syndrome. J Manip Physiol Ther. 2004;27(9):560-568.</ref><ref name="Kuschner">Kuschner SH, Ebramzadeh E, Mitchell S. Evaluation of elbow flexion and tinel tests for cubital tunnel syndrome in asymptomatic individuals. Orthopedics. 2006;29(4):305-308.</ref> Risk factors include: head injuries with upper extremity flexion contractures, age &gt; 40, overhead throwers, work that involves prolonged periods of elbow flexion such as holding a telephone, and resting elbows on a hard surface.<ref name="Tetro" /><ref name="Bartels">Bartels RHMA, Verbeek ALM. Risk factors for ulnar nerve compression at the elbow: a case control study. Acta Neurochir Wien. 2007;149:669-674.</ref><ref name="Oskay">Oskay D, Meriç A, Kirdi N, Firat T, Ayhan Ç, Leblebicioglu G. Neurodynamic mobilization in the conservative treatment of cubital tunnel syndrome: long-term follow-up of 7 cases. J Manip Physiol Ther. 2010;33(2):156-163.</ref> Entrapment can occur at multiple levels in the cubital tunnel including: the Arcade of Struthers, the medial intermuscular septum, the medial epicondyle, Osborne's ligament and the flexor-pronator aponeurosis.<ref name="Husain">Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Current Orthopaedic Practice. 2008;19(5):470-474.</ref> It may be a result of direct or indirect trauma and is vulnerable to traction, friction, and compression. Traction injuries may be the result of longstanding valgus deformity and flexion contractures, but are most common in throwers due to extreme valgus stress placed on the arm.<ref name="Lee">Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Coin North Am. 1999;30:81-89.</ref> Compression of the nerve at the cubital tunnel may occur due to reactive changes at the UCL, adhesions within the tunnel, hypertrophy of the surrounding musculature, or joint changes. <br>  
Cubital tunnel syndrome may be a result of direct or indirect trauma and is vulnerable to traction, friction, and compression. Traction injuries may be the result of longstanding valgus deformity and flexion contractures, but are most common in throwers due to extreme valgus stress placed on the arm. <ref name="Lee">Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Coin North Am. 1999;30:81-89.</ref>&nbsp;Compression of the nerve at the cubital tunnel may occur due to reactive changes at the MCL, adhesions within the tunnel, hypertrophy of the surrounding musculature, or joint changes.<ref name="Aldridge">Aldridge JW, Bruno RJ, Strauch RJ, Rosenwasser MP. Nerve entrapment in athletes. Clin Sports Med. 2001;20:95-122.</ref><br>


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Depending on the duration and progression of the disorder, patients with cubital tunnel syndrome will present with similar but specific symptoms (see Table 1).<ref name="Coppieters" /> The most common complaint for any cubital tunnel syndrome patient is paresthesias in the 4th and 5th digits that often wakes them at night.<ref name="Tetro" /> The patient may also report non-painful "snapping" or "popping" during active and passive flexion and extension of the elbow and a Wartenberg sign (abduction of the fifth digit due to weakness of the third palmar interosseous muscle) may also be present. Patients may also notice weakness while pinching, occasional clumsiness, and a tendency to drop things.<ref>ASSH. Cubital Tunnel Syndrome. http://www.assh.org/Public/HandConditions/Pages/CubitalTunnelSyndrome.aspx. Accessed November 1, 2010.</ref><br>
Early in the disorder, primary complaint is typically medial elbow pain. Numbness and tingling may also be present in the 4th and 5th digits. The patient may also report non-painful "snapping" or "popping" during active and passive flexion and extension of the elbow.&nbsp; A Wartenberg sign (abduction of the fifth digit due to weakness of the third palmar interosseous muscle) may be present. Active and passive ROM may not be decreased. The ulnar nerve may be enlarged or palpable and tender in the groove.<ref name="Sebelski">Sebelski CA. Current concepts of orthopaedic physical therapy. The Elbow: physical therapy management utilizing current evidence.</ref><br>  
 
[[Image:Symptom chart II.jpg|thumb|740x185px|Table 1 - Modified from McGowan's grading system found in Coppieters et al]]<br>
 
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== Differential Diagnosis ==
== Diagnostic Procedures ==


Differential diagnoses should include but are not limited to:<ref name="Tetro" /><ref name="Galarza">Galarza M, Gazzeri R, Gazzeri G, Zuccarello M, Taha J. Cubital tunnel surgery in patients with cervical radiculopathy: double crush syndrome?. Neurosurg Rev. 2009;32(4):471-478.</ref><ref name="Lund">Lund AT, Amadio PC. Treatment of cubital tunnel syndrome: perspectives for the therapist. J Hand Ther. 2006;19:170-179.</ref>
add text here related to medical diagnostic procedures


*<u>Cervical Radiculopathy C8-T1</u> –&nbsp;Motor and sensory deficits in a dermatomal pattern including 4th-5th digits, associated weakness of intrinsic muscles of the hand, and associated painful and often limited cervical range of motion.
== Outcome Measures  ==
*<u>Thoracic Outlet Syndrome</u> – Compression of the structures of the brachial plexus potentially leading to pain, paresthesias, and weakness in arm, shoulder, and neck.<ref name="Office">Office of Communications and Public Liaison. NINDS Thoracic Outlet Syndrome Information Page. http://www.ninds.nih.gov/disorders/thoracic/thoracic.htm. Updated July 14, 2010. Accessed November 1, 2010.</ref>
*<u>UCL Insufficiency</u> –&nbsp;Laxity of the UCL can lead to excessive or abnormal movement of structures in or around the cubital tunnel creating new sites of compression.
*<u>Pancoast Tumor</u> -&nbsp;Abnormal growth of tissue on the apex of the lung causing compression of the lower trunk of the brachial plexus.


These diagnoses present similarly to cubital tunnel with pain, paresthesias, and potential weakness; however, symptoms specific to each diagnosis allow the practitioner to rule out the doppelganger and rule in cubital tunnel syndrome. Examples of such symptoms are limited cervical motion and paresthesias in other areas outside the ulnar nerve distribution. It is important for clinicians to correctly identify this diagnosis early, as studies have shown an 88% improvement rate when treated within one year of onset as opposed to 67% improvement if treated after one year.<ref name="Tetro" /><ref name="Chan">Chan RC, Paine KWE, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transfer. Neurosurgery. 1980;7:545-550.</ref><br>  
McGowan Score, Louisiana State University Medical Center Score, Bishop Score, and Medical Research Council grade, and Northwick Park Questionnaire&nbsp;are a few outcome measures that have been used.<ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliamen L, Schubert W. Anterior transpositin compared with simple decompressin for treatment of cubital tunnel syndrome. J Bone Joint Surg Am. 2007;89:2591-8.</ref>


== Examination  ==
== Examination  ==


In order to properly diagnose cubital tunnel syndrome, a skilled physical therapist must conduct a proper physical examination including: sensory changes in the ulnar nerve distribution (ulnar ½ of the 4th digit and entirety of the 5th), vague pain, atrophy of the intrinsic muscles of the hand innervated by the ulnar nerve, a neural provocation test of the ulnar nerve, and sparing of the flexor carpi ulnaris muscle.<ref name="Boucher">Boucher B, Wainner R, Robertson E. Common disorders of the elbow-forearm complex: part II. Paper presented at: Texas State University DPT PT7559 Lecture; October 13, 2010; San Marcos, TX.</ref> Patients with this diagnosis will also present with a positive Elbow Flexion Test and a positive Tinel test. These special tests are detailed below. Not only is the examination vital to ruling in a correct diagnosis, it allows the practitioner to properly rule out patients with similar presentations.
add text here related to physical examination and assessment<br>  


<br><u>The Elbow Flexion Test</u>:&nbsp;Typically performed bilaterally with the shoulder in full external rotation and the elbow actively held in sustained maximal flexion for 1 minute with the wrist kept in neutral.<ref name="Coppieters" /> Symptoms are produced because maximal elbow flexion reduces the cubital tunnel volume by approximately 55% causing increased neural pressure on the ulnar nerve.<ref name="Kuschner" /> Some studies state this test can include additional components such as wrist extension and wrist flexion or sustained maximal elbow flexion for up to 3 minutes.<ref name="Kuschner" /> Note, these studies also state that quicker signs of a positive test are more indicative of a true diagnosis of cubital tunnel syndrome. A positive test is reproduction of pain at the medial aspect of the elbow and numbness and tingling in the ulnar distribution on the involved side. This test has a high positive predictive value (0.97), indicating a high probability of cubital tunnel syndrome if positive. Specificity (0.99) Sensitivity (0.75).<ref name="Behr">Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997;16:681-704.</ref>  
<u>The Elbow Flexion Test</u>: Typically performed bilaterally with the shoulder in full external rotation and te elbow actively held in maximal flexion with wrist extension for 1 minute. A positive test is reproduction of numbness and tingling in the ulnar distribution on the involved side. Specificity (0.99) Sensitivity (0.75).<ref name="Behr">Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997;16:681-704.</ref><br>  


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<u>The Pressure Provocative Test</u>: The clinician applies pressure at the ulnar nerve at the cubital tunnel with the UE positioned as in the elbow flexion test for 30 seconds. Sensitivity (0.91).<ref name="Novak and Lee">Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. j Hand Surg Am. 1994;19:817-820.</ref>  


<u>Tinel Sign</u>: After locating the ulnar groove posterior to the medial epicondyle of the humerus, the clinician will proceed with percussions (tapping) of the ulnar nerve as it passes through the cubital tunnel.<ref name="Coppieters" /><ref name="Kuschner" /> The number of percussions vary depending on the research, but four to six taps should be sufficient to elicit symptoms. A positive test is the reproduction of tingling and numbness in the ulnar nerve distribution on the involved side. Practitioners must be cautious with the interpretation of the test because it has been found positive in 24% of asymptomatic subjects and it could be negative for those in the advanced stage of the diagnosis because the nerve is no longer regenerating. Specificity (0.98) Sensitivity (0.70).<ref name="Novak">Novak CB, Lee GW, Mackinnon SE, Lay L. Provacative testing for cubital tunnel syndrome. J Hand Surg Am. 1994;19:817-820.</ref>&nbsp;
<u>Tinel Sign</u>: Reproduction of tingling and numbness into the 4th and 5th digits with tapping of the ulnar nerve at the cubital tunnel. Specificity (0.98) Sensitivity (0.70).<ref name="Novak and Lee" />  


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== Medical Management <br>  ==


<u>The Pressure Provocative Test</u>: The clinician applies pressure on the ulnar nerve at the cubital tunnel with the UE positioned as in the elbow flexion test for 30 seconds. Sensitivity (0.91).<ref name="Novak" /><br>  
<u>Operative Management</u>: Indications for surgical intervention include failure of conservative treatment and an electrodiagnostic test of less than 39 meters per second across the elbow.<ref name="Novak and Lee" /> Several surgical techniques have been advocated for cubital tunnel syndrome. Techniques include: simple decompression, submuscular anterior transposition, and subcuatneous anterior ulnar transposition.&nbsp; Results found no difference in motor nerve-conduction velocityies or clinical outcome scores between simple decompression and ulnar nerve transposition. <ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. J Bone Joint Surg Am. 2007;89:2591-8.</ref>  


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== Physical Therapy Management <br>  ==


== Medical Management (current best evidence)  ==
<u>Nonoperative Management</u>: Nonoperative management&nbsp; has been shown to have at least a 50% success rate with low-stage ulnar irritation. Nonoperative management may include a 4-6 week period of immoblization with the elbow splinted at 45 degrees flexion and full supination. It has been recommended that athletes have active rest from sports. Modalities may be used to treat inflammation. Return to throwing is allowed at 4-6 weeks following absence of symptoms with any daily activities or exercise and return to full ROM and strength.<ref name="Sebelski" />


Indications for surgical intervention include moderate muscle weakness without response to conservative treatment after three months and an electrodiagnostic test of less than 39-50 meters per second across the elbow.<ref name="Novak" /><ref name="Neal">Neal SL, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):147-155.</ref><ref name="Palmer">Palmer BA, Hughes TB. Cubital Tunnel Syndrome. J Hand Surg, 2010;35A:153-163.</ref>&nbsp;There have been several surgical techniques advocated for cubital tunnel syndrome including:<ref name="Yamamoto">Yamamoto K, Shishido T, Masaoka T, Katori Y, Tanaka S. Postoperative clinical results in cubital tunnel syndrome. Orthopedics. 2006;29(4):347-353.</ref>  
There is some low level evidence (case report) that has utilized nerve-gliding techniques, segmental joint manipulation and a home program consisting of nerve gliding and light free weight exercises and was able to achieve positive outcomes.<ref name="Coppieters">Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating nerve-gliding techniques in the copnservative treatment of cubital tunnel syndrome. J Manipulative Physiol Ther 2004;27:560-568.</ref>  


*<u>Simple decompression</u>: A release of Osborne’s ligament done through an incision traversing in a proximal to distal direction throughout the length of the ligament increasing the space in the cubital tunnel. It can be seen in conjunction with a medial epicondylectomy.
== Differential Diagnosis<br> ==
*<u>Medial epicondylectomy</u>: An incision is made in a proximal to distal direction parallel to ulnar nerve. The incision exposes the roof of the nerve and the medial epicondyle. The aponeurotic origin of the flexor mass is then dissected allowing partial excision of the epicondyle. The UCL is not compromised in this procedure and it can be done in addition to the simple decompression.
*<u>Anterior transposition</u> (see image<ref name="Eaton">Eaton RG, Crowe JF, Parkes JC. Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am. 1980;62:820-825.</ref>): A longitudinal curvilinear incision is made anterior to the medial epicondyle penetrating the roof to expose the nerve. A portion of the medial intermuscular septum is excised which normally provides protection for the ulnar nerve; however, it must be removed in order to expose the nerve for transposition. At the area where the nerve enters the forearm fascia (cubital tunnel), the flexor carpi ulnaris aponeurosis and the deep flexor-pronator aponeurosis are dissected and the nerve is removed from the ulnar groove and moved into the anterior aspect of the[[Image:Anterior Transposition 3.png|thumb|200x133px|Ulnar Nerve Positioned Anterior to Medial Epicondyle while Fascial Flap is Tethered to Dermis to Maintain New Position]] arm. Adipose tissue is then sutured from the anterior flap to the medial epicondyle to prevent the nerve from slipping back into the ulnar groove. There are three types of anterior transposition techniques that are named in relation to the flexor-pronator mass:<br>


&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;o Subcutaneous (above)<br>&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;o Intermuscular (within)<br>&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;o Submuscular (below)<br>  
Differential diagnosis should include cervical radiculopathy, thoracici outlet syndrome, MCL insufficiency, tophaceous gout, and calcium pyrophosphate dehydrate crystal deposition.<ref name="Sebelski" /><br>  


<br>
== Key Research  ==


As with any surgical procedure it is important for patients to understand the risks and benefits involved before making the decision to proceed with an operative treatment. While the benefits are obvious, the risks are not always apparent to patients so clinicians should be prepared to offer them some amount of insight. Fortunately, serious complications are not common with any of the aforementioned procedures, but they can be susceptible to injuring the medial antebrachial cutaneous nerve, not alleviating CBTS symptoms, and creating new points of compression.<ref name="Tetro" /><br>  
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  


Results found no significant difference in motor nerve-conduction velocities or clinical outcome scores between simple decompression and ulnar nerve transposition meaning the type of surgery is often based on surgeon and patient preference.<ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89:2592-2598.</ref> Simple decompression has shorter operative times and preserves the anatomic location of the ulnar nerve, while ulnar nerve transposition is seen by some as the only way to properly address dynamic compression of the nerve with elbow flexion. Regardless of the type of procedure it is important that the clinician is aware of what tissues were compromised and the anatomic location of the nerve in order to properly treat the post-operative patient. <br>  
Zlowodzki and Chan<ref name="Zlowodzki" />  


== Physical Therapy Management (current best evidence)  ==
Meta-Analysis of four RCT comparing simple decompression with anterior ulnar nerve transpostions. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% CI = -0.36 to 0.28], p = 0.81. Authors did not find significant heterogeneity across the studies. Two reports presented postoperative motor nerve conduction vlocities; they showed no significant difference between the the procedures. Conclusion: Data suggests that simple decompression is a reasonable alternative to anterior transposition for surgical management of ulnar nerve compression at the elbow.


Conservative treatment has been shown to have a 90% success rate in low-stage ulnar irritation with symptoms often resolving in 2-3 months.<ref name="Shriva">Shrivastava N, Szabo, RM. Decision making in upper extremity entrapment neuropathies. The Journal of Musculoskeletal Medicine, 2008;25(6), 278-280,284-285,288-289.</ref>&nbsp;Conservative treatment may include a 4-6 week[[Image:Elbow splint for CBTS.jpg|thumb|200x133px|Figure 2]] period of immobilization with the elbow splinted at 45 degrees of flexion and forearm in neutral rotation, activity modification, modalities and anti-inflammatories for inflammation, soft elbow pads, joint mobilizations, [http://www.youtube.com/user/OptimumCareProviders#p/u/107/WtH2QOuwuCU neural flossing]&nbsp;<ref>Optimum Care Providers. 8.1 Upper Limb Ulnar Nerve Mobility. http://www.youtube.com/user/OptimumCareProviders#p/u/107/WtH2QOuwuCU. Updated May 5, 2009. Accessed November 1, 2010.</ref>, [http://www.youtube.com/user/OptimumCareProviders#p/u/108/IlrJ7Ibop_4 neural gliding]&nbsp;<ref>Optimum Care Providers. 8.2 Upper Limb Ulnar Nerve Mobility. http://www.youtube.com/user/OptimumCareProviders#p/u/108/IlrJ7Ibop_4. Updated May 5, 2009. Accessed November 1, 2010.</ref>, exercise, and patient education.<ref name="Office" /><ref name="Shriva" />&nbsp;While there is strong evidence in support of splinting (Figure 2<ref name="Svernlov">Svernlov B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur 2009;34E(2):201-207.</ref>), activity modification, and patient education; only low-level evidence supports manual techniques such as nerve glides, joint mobilizations and manipulation, and exercise.<ref name="Coppieters" /><ref name="Lund" /><ref name="Svernlov" />&nbsp;Despite the low-level evidence, improvements have still been seen with manual techniques in patients with cubital tunnel syndrome. Linked in resources is an example of a treatment plan for a patient with CBTS. Please be aware the evidence to support these treatments is low; however, there is some evidence to support it.
== Resources <br>  ==
 
<br>In regards to the post-surgical CBTS patient, the general treatment plan should follow a similar pathway as those who have not undergone a surgical procedure. It will be important for the clinician to understand the different surgical techniques, tissues involved, anatomical location of the nerve, and the need to maintain contact and communication with the surgeon. Each procedure will have certain precautions that must be followed to protect the integrity of the nerve and the incision site. Linked in resources are two sample treatment plans for the post-operative patient. <br>&nbsp;<br>  
 
== Key Research ==
 
<u>Svernlov et al.<ref name="Svernlov" /></u><br>Medium RCT using three groups to compare effectiveness of elbow night splinting, self-nerve glides, and a control. A 3-month period of self-nerve gliding and instruction about the anatomy of the cubital tunnel including information about provocative positions in those with cubital tunnel syndrome resulted in increased pain-free grip strength, decreased daytime pain, and “normalized” EMG studies but was not significantly different from night splinting with instruction or instruction alone. Conclusion: All groups showed statistically significant improvements in COPM scores and night pain compared to baseline, as well as improvements in grip strength, 5th digit adduction power, and EMG studies but these changes did not reflect a statistically significant change.
 
<u>Zlowodzki et al.<ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89:2592-2598.</ref></u><br>Meta-Analysis of four RCT comparing simple decompression with anterior ulnar nerve transpositions. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% CI = -0.36 to 0.28], p = 0.81. Authors did not find significant heterogeneity across the studies. Two reports presented post-operative motor nerve conduction velocities; they showed no significant difference between the procedures. Conclusion: Data suggests that simple decompression is a reasonable alternative to anterior transposition for surgical management of ulnar nerve compression at the elbow.<br><br>


== Resources <br> ==
add appropriate resources here <br>  


[http://conservativecubitaltunneltx.webs.com/Conservative%20Treatment%20Progression%20Example.pdf Conservative Treatment of Cubital Tunnel Syndrome Example]<ref name="Coppieters" /><ref name="Neal" /><ref name="Svernlov" />&nbsp;[http://conservativecubitaltunneltx.webs.com/index.htm View Licensing Terms]
== Case Report  ==


[http://www.rcmclinic.com/pdfs/elbow-hand/ulnar_nerve_transposition.pdf Post-Surgical Treatment following Ulnar Nerve Transposition #1]<ref name="Lind">Lind CC. Ulnar nerve transposition post-operative protocol. http://www.rcmclinic.com/pdfs/elbow-hand/ulnar_nerve_transposition.pdf. Accessed November 1, 2010.</ref><br>  
Coppieters and Bartholomeeusen<ref name="Coppieters" />  


[http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/22Elbow-UlnarNerveTransposition.pdf Post-Surgical Treatment following Ulnar Nerve Transposition #2]&nbsp;<ref name="Pho">Pho C, Godges J. Ulnar Nerve Transposition. http://xnet.kp.org/socal_rehabspecialists/ptr_library/03ElbowRegion/22Elbow-UlnarNerveTransposition.pdf. Accessed November 1, 2010.</ref><br>
The objective was to discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The patient was a 17 year old female with traumatic onset of cubital tunnel syndrome. She had pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative.&nbsp; Segmental cervicothoracic motion dysfunctions were presentwhich were regarded as contributing factors hindering natural recovery. Six treatments included nerve-gliding techniques, segmental joint manipulation, and a home program of nerve gliding and light free-weight exercises. Substantial improvement was recorded on both the impairment and functional level. Symptoms did not recur within 10-month follow-up period. Pain and disability had completely resolved.  


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


With CBTS being the most common ulnar nerve neuropathy and the 2nd most common upper extremity neuropathy, early detection through sound differential diagnosis is key to ensuring best possible patient outcomes. As skilled clinicians we must tailor our treatment to each patient, post-surgical or not, in a manner that follows surgeon precautions and aims to normalize the sensitivity of the nerve, nerve biomechanics, and restores or prevents secondary complications. With insufficient quality evidence to support conservative management of CBTS, we need more randomized controlled trials to determine the effectiveness of current treatment trends.<br>  
add text here <br>  


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
== References  ==


see [[Adding References|adding references tutorial]].  
References will automatically be added here, see [[Adding References|adding references tutorial]].  


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[[Category:Texas_State_University_EBP_Project]]
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Articles]] [[Category:Condition]] [[Category:Elbow]] [[Category:EIM_Student_Project_2]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Neurodynamics]]

Revision as of 21:42, 5 June 2011

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editor - Adam West, Fitim Camaj

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Search Strategy[edit | edit source]

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Definition/Description[edit | edit source]

Cubital tunnel syndrome is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow.

Clinically Relevant Anatomy[edit | edit source]

The ulnar nerve is comprised of nerve roots C8 and T1. The ulnar nerve can become compressed withiin the cubital tunnel at multiple levels including: the arcade of Struthers, the medial intermuscular septum, the medial epicondyle, Osborn's ligament at the cubital tunnel and the flexor-pronator aponeurosis.[1]

Epidemiology /Etiology[edit | edit source]

Cubital tunnel syndrome may be a result of direct or indirect trauma and is vulnerable to traction, friction, and compression. Traction injuries may be the result of longstanding valgus deformity and flexion contractures, but are most common in throwers due to extreme valgus stress placed on the arm. [2] Compression of the nerve at the cubital tunnel may occur due to reactive changes at the MCL, adhesions within the tunnel, hypertrophy of the surrounding musculature, or joint changes.[3]

Characteristics/Clinical Presentation[edit | edit source]

Early in the disorder, primary complaint is typically medial elbow pain. Numbness and tingling may also be present in the 4th and 5th digits. The patient may also report non-painful "snapping" or "popping" during active and passive flexion and extension of the elbow.  A Wartenberg sign (abduction of the fifth digit due to weakness of the third palmar interosseous muscle) may be present. Active and passive ROM may not be decreased. The ulnar nerve may be enlarged or palpable and tender in the groove.[4]

Diagnostic Procedures[edit | edit source]

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Outcome Measures[edit | edit source]

McGowan Score, Louisiana State University Medical Center Score, Bishop Score, and Medical Research Council grade, and Northwick Park Questionnaire are a few outcome measures that have been used.[5]

Examination[edit | edit source]

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The Elbow Flexion Test: Typically performed bilaterally with the shoulder in full external rotation and te elbow actively held in maximal flexion with wrist extension for 1 minute. A positive test is reproduction of numbness and tingling in the ulnar distribution on the involved side. Specificity (0.99) Sensitivity (0.75).[6]

The Pressure Provocative Test: The clinician applies pressure at the ulnar nerve at the cubital tunnel with the UE positioned as in the elbow flexion test for 30 seconds. Sensitivity (0.91).[7]

Tinel Sign: Reproduction of tingling and numbness into the 4th and 5th digits with tapping of the ulnar nerve at the cubital tunnel. Specificity (0.98) Sensitivity (0.70).[7]

Medical Management
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Operative Management: Indications for surgical intervention include failure of conservative treatment and an electrodiagnostic test of less than 39 meters per second across the elbow.[7] Several surgical techniques have been advocated for cubital tunnel syndrome. Techniques include: simple decompression, submuscular anterior transposition, and subcuatneous anterior ulnar transposition.  Results found no difference in motor nerve-conduction velocityies or clinical outcome scores between simple decompression and ulnar nerve transposition. [5]

Physical Therapy Management
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Nonoperative Management: Nonoperative management  has been shown to have at least a 50% success rate with low-stage ulnar irritation. Nonoperative management may include a 4-6 week period of immoblization with the elbow splinted at 45 degrees flexion and full supination. It has been recommended that athletes have active rest from sports. Modalities may be used to treat inflammation. Return to throwing is allowed at 4-6 weeks following absence of symptoms with any daily activities or exercise and return to full ROM and strength.[4]

There is some low level evidence (case report) that has utilized nerve-gliding techniques, segmental joint manipulation and a home program consisting of nerve gliding and light free weight exercises and was able to achieve positive outcomes.[8]

Differential Diagnosis
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Differential diagnosis should include cervical radiculopathy, thoracici outlet syndrome, MCL insufficiency, tophaceous gout, and calcium pyrophosphate dehydrate crystal deposition.[4]

Key Research[edit | edit source]

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Zlowodzki and Chan[5]

Meta-Analysis of four RCT comparing simple decompression with anterior ulnar nerve transpostions. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% CI = -0.36 to 0.28], p = 0.81. Authors did not find significant heterogeneity across the studies. Two reports presented postoperative motor nerve conduction vlocities; they showed no significant difference between the the procedures. Conclusion: Data suggests that simple decompression is a reasonable alternative to anterior transposition for surgical management of ulnar nerve compression at the elbow.

Resources
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Case Report[edit | edit source]

Coppieters and Bartholomeeusen[8]

The objective was to discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The patient was a 17 year old female with traumatic onset of cubital tunnel syndrome. She had pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative.  Segmental cervicothoracic motion dysfunctions were presentwhich were regarded as contributing factors hindering natural recovery. Six treatments included nerve-gliding techniques, segmental joint manipulation, and a home program of nerve gliding and light free-weight exercises. Substantial improvement was recorded on both the impairment and functional level. Symptoms did not recur within 10-month follow-up period. Pain and disability had completely resolved.

Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Current Orthopaedic Practice: 2008;19(5):470-474.
  2. ↑ Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Coin North Am. 1999;30:81-89.
  3. ↑ Aldridge JW, Bruno RJ, Strauch RJ, Rosenwasser MP. Nerve entrapment in athletes. Clin Sports Med. 2001;20:95-122.
  4. ↑ 4.0 4.1 4.2 Sebelski CA. Current concepts of orthopaedic physical therapy. The Elbow: physical therapy management utilizing current evidence.
  5. ↑ 5.0 5.1 5.2 Zlowodzki M, Chan S, Bhandari M, Kalliamen L, Schubert W. Anterior transpositin compared with simple decompressin for treatment of cubital tunnel syndrome. J Bone Joint Surg Am. 2007;89:2591-8. Cite error: Invalid <ref> tag; name "Zlowodzki" defined multiple times with different content
  6. ↑ Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997;16:681-704.
  7. ↑ 7.0 7.1 7.2 Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. j Hand Surg Am. 1994;19:817-820.
  8. ↑ 8.0 8.1 Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating nerve-gliding techniques in the copnservative treatment of cubital tunnel syndrome. J Manipulative Physiol Ther 2004;27:560-568.
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