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As an evidence-based chiropractor, you see enough cases of carpal tunnel syndrome to recognize that it’s the most pervasive peripheral nerve entrapment in the upper extremity, but can you guess the second most common?

A. Radial Tunnel

B. Pronator Teres

C. Cubital Tunnel

D. Wartenberg’s

If you guessed Cubital Tunnel Syndrome, you’re correct. (1,18,20) This week’s video blog will demonstrate the essential tools to solve this frequently overlooked runner-up that burdens up to 6% of the population. (19) You’ll learn the top assessments, treatments, and nerve flossing exercises in less than three minutes!

1. Etiology

Elbow flexion requires the ulnar nerve to both stretch and slide through the cubital tunnel. As the elbow flexes, the distance between the medial epicondyle and olecranon increases, thereby stretching the ulnar nerve. Flexion also tensions the fascia/ retinaculum, resulting in ovoid deformation and reduced cubital tunnel volume. Sustained traction or compression may exceed the nerve’s resiliency, leading to cubital tunnel syndrome symptoms (2).

Cubital tunnel syndrome is commonly seen in baseball, tennis, and racquetball players. Workers who maintain sustained elbow flexion, such as holding a tool or telephone, or those who press the ulnar nerve against a hard surface, like a desk, are at increased risk. Cubital tunnel syndrome has been coined cell phone elbow.

Did You Know?

  • Women’s elbows have a thicker fat pad on the medial aspect providing greater protection; men experience cubital tunnel complaints 3-8 times more often than women. (4)
  • Cubital tunnel presents 50% more frequently on the left side, regardless of handedness. (13)

2. Clinical Findings

  • Patients presenting with cubital tunnel often complain of symptoms extending distally from the medial epicondyle to the 4th and 5th digit. 
  • Symptoms may vary from vague hypersensitivity to pain. 
  • Since motor fibers are located deep to sensory fibers, sensory irritation precedes motor deficits. 
  • Like many other neuropathies, nocturnal symptoms are common.
Ulnar nerve self-stretch

Ulnar nerve self-stretch

The Ulnar nerve self-stretch, aka Elbow flexion test, is the best diagnostic maneuver for identifying cubital tunnel syndrome. (6,7,8) The test entails maintaining shoulder abduction while flexing the elbow past 90 degrees, supinating the forearm, extending the wrist with thumb/ index opposition. A positive test results in reproduction of the chief complaint within 60 seconds.

Ulnar nerve self-stretch

Ulnar nerve self-stretch

The Ulnar nerve self-stretch, aka Elbow flexion test, is the best diagnostic maneuver for identifying cubital tunnel syndrome. (6,7,8) The test entails maintaining shoulder abduction while flexing the elbow past 90 degrees, supinating the forearm, extending the wrist with thumb/ index opposition. A positive test results in reproduction of the chief complaint within 60 seconds.

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3. Management

  • Activity modification to limit prolonged flexion and direct pressure is the key to successful management. 
  • Patients should avoid sleeping with fully flexed elbows. A night-time elbow splint that limits flexion may be helpful (30-45 degrees of flexion is thought to be the optimal position to decrease intraneural pressure). (9) 
  • A protective pad to limit repetitive daytime trauma from work or sports may prove useful.
  • The most common duration of conservative care is three months. (11) 
  • Consideration of surgical decompression is warranted for symptoms lasting over 12 weeks or in the presence of a significant motor deficit.

Nerve gliding & flossing are cornerstones of conservative management for most peripheral nerve entrapments. Ulnar nerve flossing has shown remarkable benefit for cubital tunnel patients. (22) Consider adding this Ulnar nerve self-floss to your home advice for cubital tunnel patients.

Ulnar nerve floss

Ulnar nerve floss

Hold your arm in front of you with your elbow, wrist, and fingers straight as though you are getting ready to shake hands. Touch the tips of your thumb and first finger together to make a ring. Slowly flex your elbow until your hand reaches your face. The ring position should be maintained, and your forefinger should be just beneath your eye socket. Slowly raise your elbow to flip the ring up into a monocle around your eye. Lower your arm back to the starting position and repeat ten repetitions three times per day or as directed.

Ulnar nerve floss

Ulnar nerve floss

Hold your arm in front of you with your elbow, wrist, and fingers straight as though you are getting ready to shake hands. Touch the tips of your thumb and first finger together to make a ring. Slowly flex your elbow until your hand reaches your face. The ring position should be maintained, and your forefinger should be just beneath your eye socket. Slowly raise your elbow to flip the ring up into a monocle around your eye. Lower your arm back to the starting position and repeat ten repetitions three times per day or as directed.

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References
  1. Nicholas, J.A. The Upper Extremity in Sports Medicine, CV Mosby, 1990 p.343.
  2. Wilgis EF, Murphy RD. The significance of longitudinal excursion in peripheral nerves. Hand clinics. 1986 Nov;2(4):761-6. Link
  3. Charness ME. Unique upper extremity disorders of musicians. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1992 Jul:227-52.
  4. 4. Contreras MG, Warner MA, Charboneau WJ, Cahill DR. Anatomy of the ulnar nerve at the elbow: potential relationship of acute ulnar neuropathy to gender differences. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists. 1998;11(6):372-8. Link
  5. Sarwark JF. Essentials of musculoskeletal care. American Academy of Orthopedic Surgeons.
  6. Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubital tunnel syndrome. Clinical orthopaedics and related research. 1988 Aug(233):213-6. Link
  7. Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. The Journal of hand surgery. 1992 Jan 1;17(1):86-9. Link
  8. Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. The Journal of hand surgery. 2011 May 1;36(5):782-7. Link
  9. Yamaguchi K, Sweet FA, Bindra R, Gelberman RH. The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. Journal of shoulder and elbow surgery. 1999 Jan 1;8(1):17-21. Link
  10. Rayegani SM, Raeissadat SA, Kargozar E, Rahimi-Dehgolan S, Loni E. Diagnostic value of ultrasonography versus electrodiagnosis in ulnar neuropathy. Medical Devices (Auckland, NZ). 2019;12:81. Link
  11. Kooner S, Cinats D, Kwong C, Matthewson GD, Dhaliwal G. Conservative treatment of cubital tunnel syndrome: A systematic review. Orthopedic Reviews. 2019 Jun 12;11(2). Link
  12. Gündüz A, Candan F, Asan F, Uslu F, Uzun N, Karaali-Savrun F. Ulnar Neuropathy at Elbow in Patients With Type 2 Diabetes Mellitus. Journal of clinical neurophysiology: official publication of the American Electroencephalographic Society. 2019 Aug. Link
  13. Ashworth NL, Huang C, Chan KM. Laterality and risk factors for ulnar neuropathy at the elbow. Muscle & Nerve. 2019 Oct 10. Link
  14. Martínez-Aparicio C, Jääskeläinen SK, Puksa L, Reche-Lorite F, Torné-Poyatos P, Paniagua JS, Falck B. Constitutional risk factors for focal neuropathies in patients referred for EMG. European journal of neurology. 2019 Nov. Link
  15. Lee SK, Hwang SY, Choy WS. Validity of computed tomographic measurements and morphological comparison of cubital tunnel in idiopathic cubital tunnel syndrome. BMC Musculoskeletal Disorders. 2020 Dec 1;21(1):76. Link
  16. Rydberg M, Zimmerman M, Gottsäter A, Nilsson PM, Melander O, Dahlin LB. Diabetes mellitus as a risk factor for compression neuropathy: a longitudinal cohort study from southern Sweden. BMJ Open Diabetes Research and Care. 2020 Apr 1;8(1):e001298. Link
  17. Lee SK, Hwang SY, Kim SG, Choy WS. Analysis of the Anatomical Factors Associated with Cubital Tunnel Syndrome. Orthopaedics & Traumatology: Surgery & Research. 2020 Apr 30. Link
  18. Cutts S. Cubital tunnel syndrome. Postgraduate medical journal. 2007 Jan 1;83(975):28-31. Link
  19. An TW, Evanoff BA, Boyer MI, Osei DA. The prevalence of cubital tunnel syndrome: a cross-sectional study in a US metropolitan cohort. The Journal of bone and joint surgery. American volume. 2017 Mar 1;99(5):408. Link
  20. Chauhan M, Anand P, Das JM. Cubital Tunnel Syndrome. StatPearls [Internet]. 2020 Mar 24.Link 
  21. Kooner S, Cinats D, Kwong C, Matthewson G, Dhaliwal G. Conservative treatment of cubital tunnel syndrome: A systematic review. Orthopedic reviews. 2019 May 23;11(2). Link
  22. Svernlöv B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. Journal of Hand Surgery (European Volume). 2009 Apr;34(2):201-7. Link

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