Cubital Tunnel Syndrome
- 1 Definition/Description
- 2 Clinically Relevant Anatomy
- 3 Epidemiology /Etiology
- 4 Characteristics/Clinical Presentation
- 5 Diagnostic Procedures
- 6 Outcome Measures
- 7 Examination
- 8 Medical Management
- 9 Physical Therapy Management
- 10 Differential diagnosis
- 11 Key Research
- 12 Resources
- 13 Case Report
- 14 Clinical Bottom Line
- 15 Recent Related Research (from Pubmed)
- 16 References
Cubital tunnel syndrome is a peripheral nerve compression syndrome. It is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow. This is also called an entrapment of the ulnar nerve and is the second most common compression neuropathy in the upper extremity following carpal tunnel syndrome.  It represents a source of considerable discomfort and disability for the patient and may in extreme cases lead to loss of function from the hand. Cubital tunnel syndrome is often misdiagnosed.
Peripheral nerve compression syndromes consist of chronic irritation and pressure lesions on sites where nerves have to pass through narrow anatomic spaces and fibro- osseous. The main clinical manifestation of this type of compression syndromes are paresthesia, sensory impairment and paresis. 
Cubital tunnel syndrome can also be caused by traction, pressure or ischemia of the ulnar nerve which passes through the cubital tunnel at the medial side of the elbow.
The pain or paraesthesia in the fourth and fifth finger and pain in the medial aspect of the elbow which may extend proximally or distally is caused by the compression of the ulnar nerve. The occurrence of cubital tunnel syndrome is associated with “holding a tool in position”. However there's only limited evidence that prove the effectiveness of nonsurgical and surgical interventions to treat cubital tunnel syndrome.  
Clinically Relevant Anatomy 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. 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 roof of the cubital tunnel is formed by the cubital tunnel retinaculum (also known as Osborne’s ligament) which is about 4 mm between the medial epicondyle and the olecranon. The floor of the tunnel consists of the elbow joint capsule and the posterior band of the medial collateral ligament of the elbow. It contains several structures; the most important of these is the ulnar nerve.
After passing through the cubital tunnel, the ulnar nerve is inserted deep into the forearm between the ulnar and humeral heads of the flexor carpi ulnaris.
The ulnar nerve entrapment can occur at 5 sites around the elbow:
- Arcade of Struthers (approximately 10cm proximal to the medial epicondyle)
- Medial intermuscular septum (runs from the arcade to the epicondyle)
- Medial epicondyle
- Cubital tunnel (retinaculum)
- Deep flexor pronator aponeurosis (about 5cm distal to the epicondyle)
Out of all the 5 sites, the cubital tunnel is the most common site for entrapment.
Epidemiology /Etiology Cubital tunnel syndrome may be a result of direct or indirect trauma because the ulnar nerve 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.  One of the most common pathogenetic mechanisms is intermittent traction when the ulnar nerve becomes fixed at a single or several points which limits the free gliding of the nerve. 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.
Cubital tunnel syndrome consists of compression of the ulnar nerve in the cubital tunnel under Osborne’s ligament and often with a conductive component from nerve stretching. The cause of this syndrome can be classified into primary or secondary reasons:
- Primary (idiopathic) include: anatomical variants such as subluxation of the ulnar nerve or an epitrochlearis-anconeus muscle which is a rare cause of cubital tunnel syndrome. 
- Secondary (symptomatic) include: a delayed ulnar paresis due to trauma or elbow arthrosis. It can also be caused by extra neural or, less commonly, intraneural masses, such as a lipoma or ganglion.
There are many factors which can lead to cubital tunnel syndrome. They include:
- Mechanical factors such as stretching of, friction on or compression of the ulnar nerve  
- Direct trauma or other space-occupying lesion, repetitive elbow flexion/extension, repetitive overhead activities, traction, subluxation of the ulnar nerve from the ulnar groove, metabolic disorders, congenital deformities, synovial cysts, anatomical irregularities, arthritis, joint inflammation, and occupational/athletic factors.
- head injuries with upper extremity flexion contractures
- age older than 40
- overhead throwers
- work that involves prolonged periods of elbow flexion such as holding a telephone
- resting elbows on a hard surface
Symptoms can sometimes be associated with other conditions such as: osteoarthritis, rheumatoid arthritis and other diseases, for example: diabetes mellitus, haemophilia.
Symptoms can be aggravated by alcoholism, obesity and smoking.
Depending on the duration and progression of the disorder, patients with cubital tunnel syndrome will present with similar but specific symptoms (see Table 1). Early in the disorder, primary complaint is typically medial elbow pain or aching in the forearm.  Numbness and tingling may also be present in the 4th and 5th digits, the ulnar side of the dorsum of the hand and the hypothenar eminence.  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. On observation, there may be atrophy of the intrinsic muscles of the hand, which is often not noticed by the patient, with abnormal claw posture of the 4th and 5th fingers 
There are many different ways to grade this neuropathy. There have been some studies on whether or not these ways have a clinical meaning and if they can be used as guidelines for therapy. These studies aren't conclusive. 
Patients suffering from cubital tunnel syndrome are 4 times more likely to present with atrophy than patients suffering from carpal tunnel syndrome. The ulnar nerve dysfunction has been divided into three categories by McGowan and has modified by Dellon:
• Mild nerve dysfunction implies intermittent paraesthesia and subjective weakness.
• Moderate dysfunction presents with intermittent paraesthesia and measurable weakness.
• Severe dysfunction is characterized by persistent paraesthesia and measurable weakness.
The diagnosis is established by the history and physical examination, along with the findings of electro-physiologic studies and imaging.
- with high-resolution neuro-ultrasonography, demonstration of changes in the size and position of the ulnar nerve at the elbow (also of changes in the echo texture of the nerve)
- magnetic resonance neurography (MRN) enables the visualization of structural changes of the ulnar nerve and its environment 
X-rays can be used to look for degenerative changes of the cervical spine and elbow, as well as bony compression from spurs or previous fractures. In establishing diagnosis, neurophysiological studies are helpful and should be done if surgery is planned, in order to document preoperative baseline. Ulnar nerve velocity of <50 m/s at the elbow is considered positive for cubital tunnel syndrome. 
Tinel’s signs are also used in the diagnostic procedure. These are also used in the diagnosis of tarsal tunnel syndrome.
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. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short Form-12 can also be use. 
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.
Tests used to confirm the diagnosis of cubital tunnel syndrome are those linking the ulnar neuropathy and the elbow. These tests should evoke provocative signs as a reaction to confirm this syndrome such as: elbow flexion reproducing symptoms, positive Tinel’s sign tested at the elbow or a sign of instability, for example the snapping of the ulnar nerve over the medial epicondyle with elbow flexion.
Elbow Flexion Test: Typically performed bilaterally with the shoulder in full external rotation and the elbow actively held in maximal flexion with wrist extension for one minute. Symptoms are produced because maximal elbow flexion reduces the cubital tunnel volume by approximately 55% causing increased neural pressure on the ulnar nerve. 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. 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).
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).
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). The clinician will proceed with percussions (tapping) on the ulnar nerve as it passes through the cubital tunnel after the ulnar groove posterior of the medial epicondyle of the humerus is located.  The number of percussions may vary depending on the research, but four to six taps should be sufficient to obtain symptoms. A positive test is the reproduction of tingling and numbness in the ulnar nerve distribution on the involved side. Cautions must be taken in 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 due to the fact that the nerve is no longer regenerating. 
Scratch Collapse Test: To perform the scratch collapse test, the patient’s skin is lightly scratched by the examiner over the area of nerve compression while the patient performs resisted bilateral shoulder external rotation. A brief loss of muscle resistance will be elicited if the patient has allodynia due to the compression neuropathy. Sensitivity for the scratch collapse was 69% compared with 54% and 46% for Tinel test and elbow flexion compression test, respectively. Of all tests for cubital tunnel, Tinel test had the highest negative predictive value (98%).
Operative Management: 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. Surgery may also be indicated in cases of:
● progressive symptoms,
● sensorimotor deficits,
● lack of clinical and electro-neurographic improvement
● worsening of the objective findings on follow up several weeks after the initial visit.
There have been several surgical techniques advocated for cubital tunnel syndrome including: Results found no difference in motor nerve-conduction velocities or clinical outcome scores between simple decompression and ulnar nerve transposition. 
- Simple decompression: 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. A 6- to 10-cm incision is made along the course of the ulnar nerve between the medial epicondyle and the olecranon. Care should be taken to avoid the branches of the medial antebrachial cutaneous nerve. Osbourne’s ligament is released as are the FCU superficial and deep fascia. It has been shown to be successful in treating cubital tunnel syndrome. Data suggests that in situ decompression is a reliable treatment with a low failure rate, and anterior trans-positioning can be used to treat those patients with recurrent symptoms. Decompression is the most commonly performed surgical treatment.  It can be done in conjunction with a medial epicondylectomy.
- Medial epicondylectomy: 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. Geutjens et al. have found limited evidence that shows that the medial anterior epicondylectomy offers a significantly better pain score than the ulnar nerve transposition in the treatment of cubital tunnel syndrome at long-term follow-up.
- Anterior transposition (see image): 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 arm.
There are three types of anterior transposition techniques that are named in relation to the flexor-pronator mass:
- Subcutaneous (above) - the goal is to move the ulnar nerve anterior to the elbow axis of flexion, decreasing the tension on the nerve.
- Intramuscular (within) - proponents of this technique believe that this places the nerve in a straighter line across the elbow joint. Opponents argue that scarring of the nerve can be caused, which serves as the bed for the transposed nerve. The procedure is similar to the subcutaneous trans-positioning; however a groove is created in the flexor-pronator muscle mass to serve as a tract into which the nerve is transposed.
- Submuscular (below) - some surgeons prefer to place the nerve complete beneath the flexor-pronator mass. The branches of the medial antebrachial cutaneous nerve are identified and protected. The ulnar nerve is identified and decompressed as in subcutaneous trans-positioning.
A recent study from 2014 investigated whether fascia wrapping would be a good surgical method and it found good results. Fascia wrapping is a type of sub-facial trans-positioning. This method provides better immobilization and requires less dissection than a sub-fascial transposition. All surgical treatments have disadvantages and advantages. It depends on the surgeon which method will be used. 
Selection of a surgical approach is based on the etiology of nerve compression, anatomic variations, and the surgeon’s experience. With careful protection of the medial antebrachial cutaneous nerve and careful complete decompression of the nerve around the elbow, with or without transposition, good results can be obtained.
Physical Therapy Management
Conservative treatment has been shown to have a 90% success rate in low-stage ulnar irritation with symptoms often resolving in 2-3 months. Nonsurgical treatment should be tried for at least 3 months before surgical intervention, especially in mild cases. Conservative treatment may include a 4-6 week 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, neural flossing , neural gliding , exercise and patient education.  While there is strong evidence in support of splinting (Figure 2), activity modification and patient education, only low-level evidence supports manual techniques such as nerve glides, joint mobilizations and manipulation, and exercise. 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.
The initial goal of the conservative treatment for cubital tunnel syndrome is to control and decrease paraesthesia and pain. When the symptoms are mild and aggravating activities can be identified, the first step is eliminating those pain provocative activities. When symptoms occur in a wider range of activities which also possibly include work, therapy becomes more complex and can consist of activity modifications, splinting and rest. With this combination, pain and paraesthesia become more controllable.
Therapy begins with education about the development of the symptoms and how certain activities can have an influence on these symptoms. The therapist begins with explaining the origin of the ulnar nerve and how it is orientated in one’s body. This makes it easier to explain how certain movements can provoke pain such as stretching or compressing the nerve when collaterally tilting the head or abducting, depressing or external rotating the shoulder, supinating the forearm or extending the wrist. The therapist has to teach the patient to be able to analyse these movements during everyday activities and to make sure that provoking movements are not being made repetitively, which could cause aggravation of the symptoms. For many patients this could mean a lifelong management.
Other studies show that the effect of rigid night splinting for a time period of three months combined with activity modification seems to be a successful. It has been proven that prolonged elbow flexion (static or repetitive) brings strain on the ulnar nerve and it increases extraneural and intraneural pressure in the cubital tunnel. The lowest value of these pressures is at an elbow position of 40-50 degrees of flexion. It has also been proven that pressures are significantly higher in full flexion or extension of the elbow. Splinting is meant to alleviate symptoms and prevent the progressive dysfunction of nerves.  There are two issues that should bear consideration: the ability of the splint to maintain the elbow at the ideal amount of flexion and patient compliance with night splinting.
Beside education of the patient, immobilizing the elbow by the use of splints can reduce swelling and can help to identify the location of nerve irritation. Splinting the elbow in an appropriate way allows the nerve and the surrounding structures to rest and have relief from traction and compression. This method of therapy can be combined with the usage of local steroid injections which cause relief of pain and swelling. Though steroid injections can have positive effects, therapist has to keep in mind that this treatment can have complications such as scarring and atrophy.
Lund and Amadio point out that in their opinion, avoiding symptom provoking activities can be the most important issue in the therapy of cubital tunnel syndrome. This might also be the most expensive component as the patient may require assistance at home and in the case when during work the symptoms aggravate, it is also not possible for the patient to continue working. Patients are more desperate for a solution and they expect that medical professionals should come up with a fast and effective solution to their problems. This is a big challenge for professionals, as the recovery period of nerves is in some cases unpredictable.
Applying ice can also be a solution for reducing pain and swelling, which can be combined with gently applied active range of motion exercises. Patients should know that it’s not recommended to apply ice for longer than 60 minutes.
Ultrasound therapy is also an option but only in the case when used properly and with caution as it is also shown to cause further nerve damage when used on inappropriate intensity. This can slow down the speed of recovery.
Active range of motion exercises should be initiated within range of comfort, which means up to the point where the patient still does not experience any pain when moving. Stretching can be applied within tolerance and only after the level of pain has decreased.
- Cervical Radiculopathy C8-T1 – 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.
- Thoracic Outlet Syndrome – Compression of the structures of the brachial plexus potentially leading to pain, paresthesias, and weakness in arm, shoulder, and neck.
- UCL Insufficiency – Laxity of the UCL can lead to excessive or abnormal movement of structures in or around the cubital tunnel creating new sites of compression.
- Pancoast Tumor - 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.
Additional diagnoses to consider include tophaceous gout and calcium pyrophosphate dehydrate crystal deposition.
Cubital tunnel syndrome can be often misdiagnosed as C7 syndrome or other circulatory disturbance for example Raynaud's disease or polyneuropathy. 
Svernlov et al.
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.
Zlowodzki et al.
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.
Journal Hand Microsurgery
Journal Hand Therapy
Journal Hand Surgery
Coppieters and Bartholomeeusen
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.
Bruce, Wasielewski and Hawke
The patient was a 21-year-old male collegiate wrestler diagnosed with cubital tunnel syndrome. He was diagnosed with cubital tunnel syndrome after 6 weeks of increasing disability and dysfunction. He was treated conservatively for 3 months without resolution of the symptoms. Surgical treatment then involved a subcutaneous ulnar nerve transposition performed to decompress the cubital tunnel. Following surgery, the athlete participated in an aggressive rehabilitation program to restore function and strength to the elbow and adjacent joints. He was cleared for full unrestricted activity 15 days following surgery and returned to varsity athletic competition in one month. Their literature review found no reported cases of cubital tunnel syndrome in wrestlers. Cubital tunnel syndrome is usually seen in throwing athletes and results from either acute trauma or repetitive activities. The athletic trainer should consider cubital tunnel syndrome as a possible pathology for nonthrowing athletes when presented with associated signs and symptoms. 
Clinical Bottom Line
Despite the significant amount of literature devoted to the diagnosis and treatment of cubital tunnel syndrome, optimal treatment often requires two very simple components of treatment - time and rest. While surgical intervention can greatly ease symptoms, successful lifelong management of cubital tunnel syndrome also demands education and a dedicated effort at activity modification. Hopefully, with better environmental work conditions and early detection by the medical community, can the expenses involved, the time spent in rehabilitation, and most importantly the pain and debility these patients experience decrease with the help of the patient and employer, and the medical management team.
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