Ulnar Neuropathy at the Elbow

Aka: Ulnar Neuropathy at the Elbow, Cubital Tunnel

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II. Epidemiology

  1. Second most common Compressive Neuropathy of the upper extremity (Carpal Tunnel is most common)

III. Anatomy

  1. Ulnar Nerve courses superficially and posterior to the medial epicondyle within the Cubital Tunnel

IV. Pathophysiology: Ulnar Nerve Paralysis

  1. Chronic Trauma to Ulnar Nerve (compression or traction)
    1. Injury as it passes behind medial epicondyle at elbow (within the Cubital Tunnel)
  2. Posterior Elbow Dislocation
    1. Also associated with posterior vascular injuries

V. Associated Conditions

  1. Medial Epicondylitis
    1. Compressive Ulnar Neuropathy occurs in 60% of Medial Epicondylitis patients
  2. Cubitus Valgus deformity
    1. Secondary to Growth Plate Fracture or infection
    2. Results in progressive Ulnar NerveStretching
  3. Shallow ulnar groove
    1. Ulnar Nerve subluxation in and out of groove
  4. Rheumatoid Arthritis
  5. Elbow Fracture and immobilization
  6. Excessive leaning on elbow
  7. Increased elbow flexion and extension

VI. Symptoms

  1. Medial Elbow Pain, Paresthesias or numbness
  2. Pain radiates from ulnar aspect of the Forearm into the fourth and fifth fingers
  3. Provocative
    1. Repetitive elbow flexion (compresses Cubital Tunnel)
    2. Elbow in full flexion overnight may cause night pain

VII. Signs

  1. Tapping or pressure over medial epicondyle (Tinel Sign at the elbow)
    1. Reproduces Paresthesias or numbness along Ulnar Nerve
    2. Radiation into Forearm and hand
  2. Evaluate for Ulnar Nerve subluxation
    1. Palpate the Ulnar Nerve as it courses behind the medial epicondyle
    2. Determine if the Ulnar Nerve subluxes with elbow flexion and extension
  3. Weakness or Atrophy suggests moderate to severe injury (or longstanding nerve injury)
    1. Forearm weakness
      1. Flexor carpi ulnaris
      2. Flexor digitorum palmaris
    2. Hypothenar weakness or atrophy
    3. Finger and thumb abduction weakness (Intrinsic Muscles of hand weakness)
    4. Clawhand Deformity (Ulnar Claw, Spinster's Claw)

VIII. Differential Diagnosis

  1. Ulnar Tunnel (Symptoms isolated to wrist)
  2. Cervical Radiculopathy (C8)

IX. Diagnostics: Electromyogram (EMG)

  1. Delayed conduction at elbow

X. Management: Initial conservative management

  1. Avoid provocative activity
  2. NSAIDs
  3. Moist heat
  4. Protect nerve from pressure (e.g. elbow pads)
  5. Corticosteroid Injection
  6. Night Splinting
    1. Elbow at 45 degrees of extension with neutral Forearm

XI. Management: Surgical Repair

  1. Indications
    1. Persistent Cubital Tunnel refractory to conservative management >3-4 months
    2. Perform early before motor dysfunction
  2. Technique
    1. Transfer nerve anterior to medial epicondyle
    2. Release of constricting bands
  3. Results in immediate relief of pain
    1. Sensory recovery delayed
    2. Motor recovery may be incomplete

XII. References

  1. Hariri (2010) Clin Sports Med 29(4): 655-75 [PubMed]
  2. Kane (2014) Am Fam Physician 89(8): 649-57 [PubMed]
  3. Neal (2010) Am Fam Physician 81(2): 147-55 [PubMed]
  4. Silver (2021) Am Fam Physician 103(5): 275-85 [PubMed]

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