Strains, sprains, and pains are a part of life for thousands of people who engage in repetitive upper extremity movements on a daily basis. For most, troubling musculoskeletal symptoms will resolve if the person rests and ices the affected limb and modifies tasks to mitigate the offending forces, positions, or habits that caused the injury. However, nerves that become irritated, compressed, or tractioned are notoriously slow to heal, sparking potentially chronic pain and disability in the form of entrapment neuropathies.

The second most common entrapment neuropathy, cubital tunnel syndrome (CuTS), can be just as disabling as carpal tunnel syndrome, the No.1 compressive neuropathy.¹ Although the ulnar nerve may sustain injury anywhere along its path, the typical site of entrapment is where the nerve is most superficial and vulnerable, within the cubital tunnel of the elbow.²

Squeeze Play

The proximity of the ulnar nerve to the “funny bone” at the medial epicondyle is anything but amusing to those experiencing CuTS. It is in this region that the ulnar nerve is most vulnerable to direct compression, sensitive to prolonged elbow flexion, and exposed to the slap of nearby flexor muscles as they repeatedly contract - any impingement on the nerve can cause relative ischemia and axonal damage.

Old elbow traumas such as articular fractures can cause bony space-occupying lesions that may rub on the nerve, as can the bone spurs associated with osteoarthritis. At times the ulnar nerve may sublux, sliding across the medial epicondyle with a click. Muscular and fascial soft tissues adjacent to the ulnar nerve at the elbow may become thick with repeated engagement, creating a friction rub on the nerve that leads to ulnar neuritis.

CuTS may be present unilaterally or bilaterally. Classic symptoms typically include deep, aching pain at the medial elbow region that may radiate proximally and distally into the mid-arm and/or mid-forearm, with numbness and tingling of the fourth and fifth digits. Initially symptoms are intermittent and related to elbow position, usually aggravated by prolonged elbow flexion beyond 90 degrees; but as the nerve injury progresses, muscular weakness and atrophy may also occur, producing clumsiness secondary to reduced pinch and grip strength.

Treatment strategies that include physical and occupational therapy intervention are essential to helping patients with CuTS manage painful symptoms, modify habits and work-related tasks to address exacerbating factors, and regain functional use of the arm and hand, whether as part of conservative treatment or following surgery.

Causes of Compression

The causes of CuTS may be nontraumatic or post-traumatic, and they are generally the result of compression, friction, and/or traction forces on the ulnar nerve that causes ischemia and inflammation.³ One nontraumatic mechanism of injury may be the increased extraneural pressure exerted on the cubital tunnel with adjacent disease pathology: Cubital tunnel pressure is significantly increased both proximally and distally upon elbow flexion in patients with elbow osteoarthritis as compared to those without OA.⁴

This type of static nerve compression may also be seen in the presence of other bony abnormalities of the elbow joint or from space-occupying lesions such as lipomas, synovial cysts, rheumatoid nodules, or loose bodies.

The incidence of CuTS is also increased when other upper extremity musculoskeletal disorders, such as medial epicondylitis or carpal tunnel syndrome, are present; congenital elbow valgus deformity may also be a precursor for CuTS due to the increased tensioning of the ulnar nerve around a longer distance.^4,5

Risk of CuTS is increased with repetitive trauma from episodic or sustained elbow flexion, direct trauma, prior elbow fracture or dislocation, and the extreme biomechanics associated with throwing sports.^4,6 The mechanism of ulnar nerve injury with throwing appears to be related to longitudinal strain factors that create tensioning of the nerve near its anatomical limits during the acceleration phase of throwing.^7,8

CuTS is estimated to occur three to eight times more frequently in men than women.^9,10 In general, males of older age and with higher body mass index appear to be more at risk.^5,11 Conversely, certain females with a lower BMI are more likely to experience CuTS, perhaps due to decreased soft tissue padding that may help protect the ulnar nerve from external compressive factors.¹¹

Occupational causes such as poor working posture, incompatible workstation setup, and type of work also appear to be a factor in the development of CuTS, particularly in cases when workers must repeatedly hold postures or tools in sustained positions. Computer users who use keyboards placed too high or too close are at increased risk due to prolonged positioning in elbow flexion.^5,10,12 

Unlike carpal tunnel syndrome, medical conditions like diabetes mellitus and hypertension and lifestyle habits like alcohol consumption do not appear to be directly linked with the onset of CuTS, although those conditions can predispose patients to compressive neuropathies in general.¹³ However, smoking seems to be associated with CuTS due to the deleterious effects of impaired blood flow to neurovascular structures.¹³

Confines of the Tunnel

Although the ulnar nerve may become compressed anywhere along its path, the region of highest risk is from 10 cm proximal to the elbow joint to 5 cm distal to the joint, with the cubital tunnel itself the most common site of compression due to its restrictive borders.¹⁴

There are five main sites of ulnar compression in and around the elbow region.¹⁵ The first site is proximal to the elbow in the medial arm where the ulnar nerve passes beneath the arcade of Struthers, a myofascial band formed by the medial triceps, medial intermuscular septum, and deep arm fascia approximately 6 cm to 10 cm above the elbow joint.¹⁶ It is at this location that the nerve is vulnerable to compression from hypertrophied triceps musculature.

As the ulnar nerve travels closer to the elbow joint, it becomes more superficial near the medial epicondyle of the humerus, where it may become compressed by osteophytes at the epicondyle or tractioned and overstretched during flexion in elbows with congenital or post-traumatic elbow valgus. Slightly more distally, the ulnar nerve travels through the epicondylar groove, where it is covered by the cubital retinaculum, a tough, fibrous band of connective tissue. It is at these second and third sites of potential compression that the ulnar nerve is susceptible to injuries of direct compression, or, in cases of nerve hypermobility, may become irritated as the nerve subluxes over the medial epicondyle.

As the ulnar nerve exits the epicondylar groove, it passes into the cubital tunnel, the fourth potential site of ulnar nerve compression. The tunnel is bordered on each side by the bones of the olecranon and the medial epicondyle, with a floor made up of ulnar collateral ligament and elbow joint capsule and a roof made of fascia (the humeroulnar arcade, HUA) — all structures that are virtually unable to expand in the presence of inflammation or thickening of the neural tissues. Here, the point of constriction typically occurs when the HUA becomes taut during elbow flexion, narrowing the already snug available space within the tunnel; an HUA thickened by repeated use can also narrow the tunnel.

Finally, the ulnar nerve exits the cubital tunnel at the forearm between muscle bellies of the flexor carpi ulnaris and flexor digitorum profundus muscles, the fifth site of potential nerve compression, approximately 4 cm distal to the medial epicondyle.

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McGowan CuTS Grading Scale

Grade I (mild): Numbness or tingling in the ulnar nerve distribution with a feeling of clumsiness in the affected hand. No intrinsic muscle wasting or weakness.

Grade II (intermediate): Paresthesias with interosseous muscle weakness and atrophy.

Grade III (severe): Paresthesias with paralysis of the interossei muscles, marked hand weakness.

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Dynamic Movement

During elbow movement from extension to flexion, the distance between the olecranon and the medial epicondyle increases 5 mm for every 45 degrees of movement.⁹ In full extension, the shape of the cubital tunnel is round; but with increasing flexion, the shape changes to an oval as the height reduces by 2.5 mm.

This results in a decreased tunnel volume of 55%, doubling the pressure on the ulnar nerve from 7 mm Hg to 14 mm Hg.⁹ The most extreme position of the upper extremity is combined shoulder abduction with elbow flexion and wrist extension (the provocative upper limb tension test position), which increases intraneural pressure of the ulnar nerve to six times that in its position of rest in extension.⁹

With movement into flexion, the ulnar nerve undergoes a traction force: At full flexion, the nerve slides longitudinally a distance of up to 10 mm proximal to the medial epicondyle and up to 6 mm distal to the epicondyle. Because the ulnar nerve passes behind the elbow’s axis of rotation, the nerve can stretch and elongate with elbow flexion by as much as 8 mm in addition to its sliding movement.³

Not only does the nerve slide within the changing shape of the cubital tunnel as the elbow moves from extension to flexion, it also changes shape, flattening significantly as the elbow bends beyond 90 degrees. It appears that the combination of nerve traction, elongation, and the changing shape of the cubital tunnel itself conspire to increase intraneural pressure that may result in ischemia.

Ulnar nerve compression within the cubital tunnel is most frequently worsened by tightness in the overlying fascial bands of the HUA that constricts the nerve within the tunnel as the upper extremity is utilized. Patients who experience subluxation of the ulnar nerve during elbow movement may also develop ulnar neuritis, caused by repeated friction on the nerve as it flicks across the medial epicondyle.

Discovering Dysfunction

The diagnosis of CuTS is made through a combination of a complete patient history and physical examination, clinical tests, and objective diagnostic studies.

Subjectively, patients will usually report paresthesias along the ulnar half of the fourth finger and the entire fifth finger, and a deep, aching pain at the medial aspect of the elbow that may radiate proximally and/or distally; pain is rarely felt in the hand. A common complaint is night pain at the elbow that awakens patients when the elbow has been in a flexed position during sleep. Other painful activities are those that overstretch the irritated nerve, such as bending the elbow to wash and dry the hair or hold a book.

Symptoms can include hand and finger clumsiness, hand weakness, and loss of grip and pinch strength such that patients report difficulty opening jars, handling keys and other small objects, and find that they drop items frequently. Some patients will report that their fifth finger gets caught on the edge of their pocket due to encroaching adductor weakness.

The physical examination should include evaluation of the hand, elbow, shoulder, and neck to rule out the possibility of elbow pain that has been referred from an alternate location. Conditions that may be mistaken for CuTS include Guyon’s canal syndrome, Raynaud phenomenon, complex regional pain syndrome, rheumatoid arthritis, medial epicondylitis, thoracic outlet syndrome, and C8 radiculopathy.

Patients should be examined for postural habits that may affect neural tension (forward head, protracted scapulae, thoracic kyphosis), and the cervical spine and upper extremity joints should be observed for normal, symmetrical range of motion. Patients with a prior history of elbow injuries or arthritis may have ROM restrictions.

Some patients may demonstrate an exaggerated carrying angle in cases of valgus deformity, or swelling near the cubital tunnel due to the presence of trapped fluids. With longstanding CuTS, the hand may appear clawed due to wasting atrophy of hand intrinsic muscles that makes the hand appear bonier than normal, combined with flexion of the fourth and fifth fingers caused by chronic ulnar-innervated muscle weakness.

Clinical Tests

Strength testing should be performed with particular attention to intrinsic muscle function and grip and pinch strength. Since the motor fibers of the ulnar nerve that supply the flexor carpi ulnaris and the flexor digitorum profundus are deeper than the fibers supplying the hand intrinsic muscles, forearm atrophy is rarely observable and strength deficits are most likely to cause impaired finger and thumb abduction. Muscles innervated by the ulnar nerve are the flexor carpi ulnaris, flexor digitorum profundus, abductor digiti minimi, adductor pollicis, the third and fourth lumbricals, and the ulnar intrinsic hand muscles.

Clinical tests to assess muscle weakness may include asking the patient to hold a piece of paper between the thumb and index finger (Froment’s sign): Patients with CuTS will not be able to maintain their grip on the paper when it is pulled away secondary to adductor pollicis and first dorsal interosseous muscle weakness, and will compensate by activating flexor pollicis longus instead (seen as flexing the tip of the thumb at the interphalangeal joint). Intrinsic muscle strength can be further assessed by observing whether the patient is able to successfully cross their fingers.

Wartenberg’s sign may also be present, in which the fifth finger assumes a position of abduction when extended, secondary to adductor weakness. Weakness of the flexor digitorum profundus may be observed with resistance testing of the distal fourth and fifth finger flexors, and flexor carpi ulnaris weakness may be noted by testing wrist flexion with ulnar deviation. Maximal grip and pinch strength testing may be quantified using a handheld dynamometer. As always, strength readings for the affected extremity should be compared to the unaffected side for context, with hand dominance taken into account.

Sensation testing may be performed via two-point discrimination and vibration tests, and by using graded monofilaments. Although pain may refer into the medial forearm, the forearm is usually spared from loss of sensation due to its innervation by the medial antebrachial cutaneous nerve. The ulnar surface of the hand dorsum is of diagnostic importance, as it is supplied by the dorsal ulnar sensory nerve: This branch exits the main ulnar nerve proximal to Guyon’s canal before reaching the hand, so when sensation in this part of the hand is intact in the presence of ulnar hand paresthesias, CuTS is a likely culprit.

The cubital tunnel itself should be palpated for tenderness, increased soft tissue density, and to exclude lesions. During elbow AROM and PROM from extension to flexion, the ulnar nerve may be palpated to assess whether the nerve subluxes out of the cubital tunnel with movement.

The elbow flexion test, a provocative clinical test similar to Phalen’s test for carpal tunnel syndrome (in which the dorsal hands are pressed together for one minute to position the wrists in 90 degrees of flexion), mechanically compresses the ulnar nerve at the cubital tunnel while tensioning the nerve.¹⁷ The elbow flexion test is performed by holding the affected elbow in a position of full flexion combined with forearm supination and full wrist extension for up to three minutes in an attempt to reproduce symptoms. The flexion test may also be performed in conjunction with gentle direct pressure over the ulnar nerve; a positive flexion test with gentle compression can provoke symptoms within 30 seconds.¹⁸

Although somewhat unreliable due to low sensitivity, tapping the ulnar nerve just posterior to the medial epicondyle (Tinel’s sign) may also reproduce symptoms of pain and tingling, indicating ulnar nerve irritability; however, in the elbow Tinel’s sign can be a nonspecific finding. A newer method called the “scratch collapse” test appears clinically useful for diagnosis of CuTS and also carpal tunnel syndrome.¹⁹ To perform the test, patients are asked to resist bilateral shoulder external rotation with the elbows flexed to 90 degrees. After the region of suspected nerve entrapment is lightly scratched, resisted external rotation testing is repeated. A positive test is one in which the patient demonstrates a loss of strength on the affected side.

Signs of Entrapment

Objective imaging tests for CuTS may include X-rays and MRIs to rule out space-occupying lesions and to identify the exact anatomical location of the lesion; ultrasound has also been used to visualize abnormal thickening of the ulnar nerve that confirms the diagnosis.²⁰ Findings such as osteophytes, cysts, tumors, and fractures can be visualized best with a slightly oblique anterior-posterior view on X-ray, known as the “cubital tunnel” view. Laboratory blood tests may be useful to determine underlying disease pathology, but unless a related medical condition is discovered, these tests are typically normal with a diagnosis of CuTS.

Electrophysiologic testing can be useful to determine the extent of and location of nerve entrapment, and it should consist of a detailed nerve conduction velocity study of both motor and sensory conduction, with needle electromyography studies of ulnar nerve-innervated musculature to determine the presence and degree of nerve compression.⁶ In patients with ulnar nerve compression the tests generally show slowed motor conduction across the elbow; however, it is possible for CuTS to be present despite a negative NCV/EMG test.

Regardless of assessment technique, it is important to diagnose CuTS accurately and quickly. The longer treatment is delayed, the more likely the damage to the ulnar nerve will become permanent. Unfortunately, patients with CuTS are more likely than those with carpal tunnel syndrome to delay seeking treatment until nerve damage has become advanced, decreasing the chances of a successful outcome.²¹

Dellon Scale for CuTS
	Sensory	Motor	Tests
Mild	Intermittent paresthesias; vibratory perception increased	Subjective weakness, clumsiness, or incoordination	Elbow flexion test or Tinel’s sign may be positive
Moderate	Intermittent paresthesias; vibratory perception normal or decreased	Measurable weakness in pinch or grip strength	Elbow flexion test or Tinel’s sign may be positive; finger crossing may be abnormal
Severe	Persistent paresthesias; vibratory perception decreased; abnormal two-point discrimination	Measurable weakness in pinch and grip strength; muscle atrophy	Positive elbow flexion test or positive Tinel’s sign may be present; finger crossing usually abnormal

 

Rehab Rewards

Treatment for CuTS is typically a combination of behavior modification, rehabilitation techniques, and if all else fails, surgery to decompress or move the nerve to a safer location. With a timely multidisciplinary approach, the outcome is usually good. Patients with CuTS must be educated about potentially aggravating daily activities, postures, and positions in order to understand and gain control over their symptoms. Avoidance of direct external compression, poor elbow positioning, and repetitive arm movements are of prime importance to symptom management.

When possible, the best approach is to identify and remove exacerbating factors, such as nighttime elbow flexion, habitually resting the arms on hard surfaces, and any activities that require repeated gripping or other engagement of the forearm flexors. Because smoking is an independent risk factor for CuTS, patients should be educated and advised about smoking cessation programs.

Successful rehabilitation for CuTS that includes physical or occupational therapy incorporates a variety of treatment strategies with the goals of reducing exacerbating factors, splinting to rest the elbow in an extended position where the nerve is less compressed, and improving functional use of the hand.

Therapists engage in a variety of procedures, including soft tissue mobilization of restrictive fascial bands, pain-relieving modalities, splinting, and instruction in workstation modification to facilitate recovery.²² For patients without muscle atrophy, conservative management may be the best approach as it is hypothesized that in up to 50% of patients, CuTS will spontaneously resolve.²³

The first objective is to alleviate symptoms by using a splint that positions the elbow in extension, especially during the unconscious hours of sleep.¹ Nocturnal elbow splints may be prefabricated, custom made, or as simple as wrapping a folded towel or pillow around the elbow. The most important criteria is that the splint prevents the wearer from flexing the elbow beyond 90 degrees throughout the night, thus reducing pressure in the cubital tunnel.^24,25

It has been suggested that positioning the elbow in slight flexion at approximately 30 degrees for nighttime is helpful, but no outcomes studies are available describing the optimal angle. Splinting alone appears to significantly improve symptoms of CuTS; the addition of a local corticosteroid injection does not seem to bring additional gains in progress; and in some cases, injection of the cubital tunnel is considered dangerous due to the risk of directly hitting the nerve and causing iatrogenic damage.²⁵

Identification of potentially aggravating positions and activities is extremely important in the treatment of CuTS, as activity modification that prevents direct and positional compression of the ulnar nerve is frequently sufficient to resolve painful symptoms.²³

At the workstation, optimal elbow positioning may be achieved by maintaining a position in which the angle of the elbow is “open” with flexion greater than 90 degrees, the wrists are in a neutral position with no ulnar deviation, and use of the computer mouse is limited. Patients who must use the mouse repeatedly or over prolonged periods of time, especially when scrolling, may overactivate the flexor carpi ulnaris and flexor digitorum profundus creating increased friction in the cubital tunnel. 

Patients with CuTS who must perform repeated upper extremity tasks, hold tools in a position of elbow flexion for long periods of time, or engage in activities that require repetitive gripping or utilization of the forearm flexors will benefit from patient education to pace those activities. Therapists can instruct patients in how to develop work/rest schedules to reduce muscle strain and extreme positioning, which allows the ulnar nerve to experience shorter periods of compression from flexed postures, less slapping of nearby contracting muscles on the nerve, and decreased longitudinal tension on the nerve. Regardless of occupation, each patient’s individual set of work dynamics must be evaluated for potential causes of ulnar nerve irritation in order to remove exacerbating factors, reduce neural irritation, and allow healing.

Direct hands-on treatment methods that address CuTS may include soft tissue mobilization to gently stretch and break up restrictive fascial bands, anti-inflammatory modalities for pain control, and neural gliding techniques. There is little research available on treatment efficacy, but one study showed that attempts to mobilize the ulnar nerve with nerve gliding techniques resulted in less strain and greater nerve excursion than techniques that produced tension along the nerve.²⁶

Although traditional treatment for CuTS focuses on immobilization of the elbow in extension and activity modification, case studies indicate treatment that implements a combination of nocturnal immobilization, nerve gliding, and light strengthening exercises may yield the greatest benefits.²⁷

In addition to hands-on treatment, adaptive equipment may be necessary to reduce the amount of gripping force needed to successfully achieve ADLs and work tasks. Ergonomically designed built-up handles can distribute gripping and pinching forces and promote a more relaxed grip. During periods of acute nerve irritation, patients are taught how to use adaptive equipment to enable manipulation of small objects, grip clothing closures, and facilitate the performance of independent ADLs.

Surgical Approaches

When conservative treatment measures fail, surgical decompression and/or transposition of the ulnar nerve is the next step to alleviate symptoms and offset further nerve damage. However, surgeons disagree on the operative criteria when the diagnosis of CuTS is present. In one study, 51% of surgeons advocated that the ulnar nerve should only be operated on when there are abnormal NCV/EMG findings; others feel that careful correlation of symptoms with clinical tests suffice.¹⁸ Most surgeons (84%) agree that the presence of muscle atrophy, as an objective sign of significant compression, dictates the need for operative treatment.¹⁸

Once the decision to operate is made, most surgeons consider more than one approach when deciding on how to alleviate CuTS symptoms. The two main approaches to ulnar nerve compression are cubital tunnel decompression or ulnar nerve transposition; to date there has been no consensus on which surgical approach is best, perhaps due to the potential for multiple sites of compression along the ulnar nerve and the difficulty in identifying the exact anatomical location of the lesion.^28,29

Decompressive surgical procedures involve mobilizing the nerve without altering its anatomical course in the ulnar groove, whereas transposition surgeries free the nerve and relocate it to a relatively safer location.

The most commonly used surgical techniques for decompression of the ulnar nerve are simple decompression and medial epicondylectomy, and those in which the ulnar nerve is relocated include subcutaneous, intramuscular, and submuscular transposition.

Decompression Surgeries

The most straightforward and least invasive procedure that decompresses the entrapped ulnar nerve is a cubital tunnel release, also known as a simple decompression.²⁸ With this surgery, the thick, fibrous aponeurosis of the HUA overlying the cubital tunnel is divided, thereby “releasing” the tunnel roof. Typically, the soft tissues are also released distally, following the nerve’s pathway between the two heads of the flexor carpi ulnaris muscle.

The goal of surgery is to gently free the nerve from perineural adhesions and tight fascial bands. Because the ulnar nerve is not moved from its natural site, there is a decreased likelihood that the nerve will suffer iatrogenic damage from surgical tools or from circulatory ischemia. Postoperatively, the arm is wrapped in a soft, bulky dressing and patients are instructed to gently move the arm through its full AROM within the first two weeks, after which active exercises can be reintroduced. Nocturnal splinting is recommended during the healing process.

Advantages of this technique include a low rate of complications and a rapid recovery; disadvantages are that the approach is only effective for nerves that are compressed within the cubital tunnel, and it does not address ulnar nerve subluxation. Simple decompressions may also be performed endoscopically to minimize soft tissue trauma, reduce scarring and risk of postoperative elbow contractures, and improve healing times.³⁰ The minimally invasive approach reduces complications and permits the surgeon to release observable compression points within the cubital tunnel, but it requires increased surgical skill.³¹

With a medial epicondylectomy, a simple decompression is performed along with removal of the medial epicondyle. This is accomplished without disruption of the ulnar collateral ligament, which is necessary for elbow joint stability. The common tendinous origin of the flexor and pronator muscles is dissected from the epicondyle and reattached to the residual bone end from which the medial epicondyle was removed. During the operation, the elbow is put through its full PROM to ensure the ulnar nerve is able to slide freely over the resected portion of the condyle.

Transposition Surgeries

Subcutaneous transposition surgery begins with a simple decompression where the fascial roof of the cubital tunnel is divided down to the flexor carpi ulnaris heads and along the proximal forearm. Proximally, the nerve is also liberated from points of entrapment as far as the triceps. The ulnar nerve is then repositioned anteriorly to the medial epicondyle and flexor-pronator muscle group.

A fascial sling is placed over the nerve to prevent it from sliding back into the ulnar groove, but not tightly enough to cause a new site of entrapment. Advantages of this approach are a more extensive dissection that addresses multiple points of compression along the nerve pathway; however, the nerve may become devascularized, kink along its new pathway or at the fascial sling, and has a longer recovery period. The intramuscular transposition is carried out in a similar fashion. The difference is that instead of a fascial sling to stabilize the new nerve position, the nerve is sewn into an intramuscular trough made by an incision in the flexor-pronator muscles. With this approach, there is an increased risk for scar tissue formation around the ulnar nerve in its new position between the muscles.

The submuscular transposition places the ulnar nerve in a more protected position beneath the pronator teres and flexor carpi ulnaris by removing the musculotendinous origin from the epicondyle and reattaching it over the nerve. The deeper position of the nerve beneath the muscles serves to better protect it from external trauma, and there is less risk of kinking. Disadvantages can include postoperative weakness of the flexor-pronator muscle group, potential nerve injury, and a long recovery period.

When deciding on which surgical approach to take, surgeons must consider the location of ulnar nerve entrapment, the individual’s underlying anatomy, and the surgeon’s experience and preference.²² Studies have shown that when comparing simple decompression to anterior subcutaneous or submuscular procedures, there is no clear winner as to positive outcomes.^32,33 Overall, there appears to be no difference in postoperative motor NCVs or clinical outcome scores regardless of the surgical approach chosen.^18,34

Regardless of the type of surgical procedure, patient outcomes are improved by timely treatment - positive predictors include increased body weight that provides protective padding over the nerve, absence of postoperative ulnar nerve subluxation, normal two point discrimination sense prior to surgery, and recent date of surgery.³⁴ Surgical complications include infection, poor wound healing, nerve injury, and elbow joint contracture.

Early postoperative mobilization facilitates ease of performing ADLs and returning to work without compromising healing.³⁵ PT and OT intervention with anti-inflammatory modalities, gentle scar tissue mobilization, ROM exercisesto prevent elbow joint contractures and to stretch tight forearm flexors, and careful progressive strengthening beginning with isometrics performed with an extended elbow can shorten the time to return to work following surgery.

Progressive exercises to restore strength to the affected hand must be prescribed on an individual basis, taking into consideration that the nerve damage was exacerbated by certain positions and repetitive movements; no series of rehabilitation is complete without an ergonomic assessment and correction of any dysfunctional positional factors that may have originally contributed to the nerve injury.

Pressure Relief

Cubital tunnel syndrome is a disabling diagnosis, but it can respond readily to conservative, nonsurgical intervention when treatment is not delayed. However, without appropriate intervention, permanent nerve damage and loss of hand function may result.

PTs and OTs are an integral part of the management team that is needed to evaluate and treat the condition quickly so as to minimize nerve damage and maximize hand function. Therapists play a critical role in teaching patients ways to reduce traction, friction, and compression on the nerve; showing patients how to protect the vulnerable elbow during work, play, and sleep; and helping the recovery process should the need for surgical decompression or transposition arise. Together with physicians and surgeons, therapists help patients regain normal sensation, strength, and hand function to perform ADLs and continue in their chosen occupation with sensible modifications that protect the ulnar nerve from further damage.