Cubital Tunnel Syndrome
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Clinically Relevant Anatomy
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Cubital tunnel syndrome is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow. 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]
Mechanism of Injury / Pathological Process
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Cubital tunnel syndrome may be a result of direct or indirect trauma and is bulnerable 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]
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]
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).[5]
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).[6]
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).[6]
Outcome Measures[edit | edit source]
McGowan Score, Louisiana State University Medical Center Score, Bishop Score, and Medical Research Council grade are a few outcome measures that have been used.[7]
Management / Interventions
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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]
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.[6] 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. [7]
Differential Diagnosis
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Key Evidence[edit | edit source]
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References[edit | edit source]
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- ↑ Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Current Orthopaedic Practice: 2008;19(5):470-474.
- ↑ Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Coin North Am. 1999;30:81-89.
- ↑ Aldridge JW, Bruno RJ, Strauch RJ, Rosenwasser MP. Nerve entrapment in athletes. Clin Sports Med. 2001;20:95-122.
- ↑ 4.0 4.1 Sebelski CA. Current concepts of orthopaedic physical therapy. The Elbow: physical therapy management utilizing current evidence.
- ↑ Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997;16:681-704.
- ↑ 6.0 6.1 6.2 Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. j Hand Surg Am. 1994;19:817-820.
- ↑ 7.0 7.1 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
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