Author(s): Thiru M. Annaswamy, MD, Sean Furlong, DO
Originally published: July 25, 2012 Last updated: May 8, 2024
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Disease/Disorder

Definition

Ulnar neuropathy at the elbow (UNE) is an injury to the ulnar nerve in the elbow region causing localized pain, intrinsic hand muscle weakness and sensory changes to the ring and little fingers. Cubital tunnel syndrome is a subtype of UNE in which the entrapment of the ulnar nerve occurs at the humeroulnar aponeurotic arcade (connecting the two heads of the flexor carpi ulnaris). Tardy ulnar palsy is a specific type of UNE that occurs after an old elbow injury.

Etiology

UNE may be caused by extrinsic or intrinsic compression or stretch of the ulnar nerve. Common etiologic factors include/prolonged elbow compression on hard surfaces, compression by normal or anomalous anatomic structures, repetitive/prolonged elbow flexion (often during sleep), perioperative positioning, chronic ulnar nerve subluxation, or acute or chronic complications of elbow trauma.

Epidemiology

UNE is common, with an approximate annual incidence of 30:100,000. This affects males > females, however females are more likely to present at an earlier age. Ulnar neuropathy at the elbow is the second most common peripheral entrapment neuropathy behind carpal tunnel syndrome.20

Patho-anatomy/physiology

Normal ulnar nerve anatomy and function:

The ulnar nerve arises from the medial cord of the brachial plexus (C8-T1) and lies posteromedial to the brachial artery in the anterior compartment of the upper arm. Next, it passes through the intermuscular septum (Arcade of Struthers) 8 cm proximal to the medial epicondyle then travels along the posterior humerus into the retroepicondylar groove posteromedial to the medial epicondyle where it passes under the aponeurosis between the two heads of the flexor carpi ulnaris muscle (i.e., the cubital tunnel).

Coursing through the forearm the ulnar nerve supplies the flexor carpi ulnaris and flexor digitorum profundus to digits 4 and 5. Distally in the forearm the dorsal ulnar cutaneous and palmer cutaneous sensory nerves supply sensation to the hypothenar eminence. At the wrist the digital sensory branch supplies sensation to the 5th digit and ulnar half of the fourth digit.

Proximal to Guyon’s canal, the ulnar nerve branches to supply the hypothenar muscles. After entering Guyon’s canal, the ulnar nerve terminates as the deep palmer motor branch, supplying the first dorsal interosseous, adductor pollicis, third and fourth lumbricals and contributes to the innervation of the flexor pollicis brevis.

The following muscles are innervated by the ulnar nerve (by location):

  • Forearm
    • Flexor Carpi Ulnaris
    • Flexor Digitorum Profundus (to digits 4 and 5)
  • Hypothenar
    • Opponens digiti minimi
    • Abductor digiti minimi
    • Flexor digiti minimi
  • Thenar
    • Adductor pollicis
    • Deep head of flexor pollicis brevis
  • Hand Intrinsics
    • Palmar interossei
    • Dorsal interossei
    • Lumbricals (to digits 4 and 5)
    • Palmaris Brevis

Common Sites of Ulnar Nerve Entrapment, proximal to distal

  • The proximal arm in the Arcade of Struthers (aponeurotic band between the medial intermuscular septum and the medial head of the triceps brachii)13
  • The cubital retinaculum/Osborne’s Ligament – a ligament from the medial epicondyle to the olecranon process of the ulna
  • The Arcade of Osborne (fascia that connects the fascia between the ulnar and humeral heads of the flexor carpi ulnaris).
  • The most common site of entrapment4 is in the retro-epicondylar groove just behind the medial epicondyle of the humerus, where there is very little soft tissue protecting the ulnar nerve from external compression.
  • At the humeroulnar arcade (also known as the cubital tunnel), an aponeurotic band about 1-2 cm distal to the medial epicondyle.
  • At the wrist as it passes through Guyon’s Canal.
  • Compression or entrapment at any of these sites may result in focal demyelination, axon loss, or both.

UNE frequently spares the ulnar innervated forearm muscles (flexor carpi ulnaris and flexor digitorum profundus to digits 4 and 5), while commonly affecting the ulnar innervated hand muscles, particularly the first dorsal interosseous muscle.18

Essentials of Assessment

History

The following presenting symptoms are the most common:

  • Paresthesias in the dorsal and palmar surfaces of the small finger, ulnar half of the ring finger, and ulnar dorsal hand.
  • Weakness or loss of coordination in the involved hand suggests motor involvement.
  • Local pain at the medial elbow that may radiate to the hand.
  • Symptoms worse at night caused by sleeping with arm in flexion

Physical examination

Thorough sensory and motor examination should be performed of the entire involved limb with comparison to the contralateral limb. It is important to evaluate for interosseous and first web space atrophy, ring and small finger clawing, decreased sensation to digits 4 & 5, weakened hand grip / pinch strength. Attention should be paid to excluding disorders that may mimic ulnar neuropathy, particularly C8 radiculopathy, lower trunk/medial cord brachial plexopathy, and carpal tunnel syndrome.

Physical Exam Findings, Special Tests, and Signs

  • Tinel’s Sign (repetitive tapping directly over the nerve) at the elbow may reproduce sensory symptoms of numbness and paresthesias in the medial 2 digits, and potentially some discomfort in the elbow region.
  • Elbow Flexion Test: the patient’s elbow is held in maximal flexion for up to 3 minutes. A positive test result includes onset or increase in sensory symptoms.
  • The shoulder internal rotation elbow flexion test is reportedly 87% sensitive and 98% specific and can be done quickly. The patient is placed in 90° of shoulder abduction, maximal shoulder internal rotation, maximum forearm supination, and maximum wrist extension. A positive test is the onset of symptoms within 5 seconds or less.15
  • Wartenberg’s Sign: when placing the affected hand in a pocket, the small finger is abducted and does not enter the pocket. This is caused by weakness of ulnar-innervated palmar interossei, which are responsible for finger adduction.
  • Froment’s Sign: when attempting to firmly grasp a sheet of paper between the thumb and index finger, thumb interphalangeal flexion suggests substitution of the median-innervated flexor pollicis longus to compensate for a weak ulnar-innervated adductor pollicis.
  • Ulnar Claw Hand/Benediction Posture: this may develop with severe denervation of hand intrinsic muscles. This is recognized by flexion of the distal interphalangeal and proximal interphalangeal joints and extension of the metacarpophalangeal joints of the ring and small fingers with attempted opening of the hand. These findings occur as a result of weakness of the third and fourth lumbricals. The ulnar claw hand should not be confused with the median nerve benediction sign, which has a similar static appearance, but occurs with attempted hand closing.
  • Palpable ulnar nerve subluxation may occur with elbow flexion and extension and may reproduce symptoms.

Functional assessment

  • A thorough occupational and avocational/recreational history to evaluate for repetitive movements should be performed.
  • Difficulty with fine motor tasks is common.
  • Diminished grip strength may impair functional or occupational tasks, including activities of daily living, such as buttoning a shirt.
  • A patient-reported outcome measure, The Patient-Rated Ulnar Nerve Evaluation (PRUNE) has been developed and validated for use in patients with UNE. It may be used on initial evaluation and to track progress over time.9

Laboratory studies

Laboratory studies, such as fasting blood sugar for diabetes or rheumatoid factor for rheumatoid arthritis, can provide ancillary data for overall patient management, but are not specific to UNE.

Imaging

  • Magnetic Resonance Imaging (MRI) and ultrasound have shown promise in the diagnostic evaluation of UNE, although their routine use is not recommended. However, given the increasing availability of bedside ultrasound in many clinical practice settings, point-of-care use of ultrasound may be a useful tool for the evaluating practitioner. Additionally, ultrasound allows for dynamic evaluation of structures, including possible identification of subluxation or dislocation of the ulnar nerve in and out of the ulnar groove with elbow flexion and extension.16
  • MRI can be used to look for enlargements of the ulnar nerve and abnormal T2 signal, both of which have shown to have high sensitivity and specificity in diagnosing UNE,6 as well as localize the lesion to the elbow in patients with non-localizing neurophysiologic evaluations.35
  • Multiple studies3,4,12 have shown that comparing cross sectional area on ultrasound of the affected ulnar nerve to normative values or a proximal site on the ulnar nerve can be used to diagnose UNE with similar sensitivities and specificities when compared to electrodiagnosis; however, ultrasound has not been shown to be of additional benefit to the patient in terms of clinical outcomes, when combined with electrodiagnostic tools.10 A 2020 meta-analysis of ulnar nerve cross sectional area (CSA) evaluations indicated that measurement of ulnar nerve CSA at the medial epicondyle provided 80% sensitivity with a cutoff value of 10-10.5 mm2 or greater. Higher specificities were obtained using nerve CSA ratios, though there was more variation between studies in cutoff values.14 Another study using ultrasound evaluation demonstrated a twofold occurrence of anatomic abnormalities, such as the presence of an anconeus epitrochlearis muscle, an accessory triceps head, or space occupying lesion, and a twofold occurrence rate of ulnar nerve dislocation in arms with UNE compared to control arms (49% vs 23%).16

Supplemental assessment tools

Electrodiagnostic testing is useful to confirm the diagnosis of UNE, as well as to differentiate UNE from ulnar neuropathy at the wrist, cervical radiculopathy, polyneuropathy or median mononeuropathy. Current AANEM practice parameters are as follows.5

Nerve Conduction Studies (NCSs)

  • More accurate measurement with elbow flexed as an extended elbow may underestimate the conduction velocity.
  • Routine ulnar sensory and motor NCSs. Motor studies should include recording at the adductor digiti mini, however, ulnar neuropathy is often fascicular and additional recording at the first dorsal interosseous muscle may increase sensitivity.
  • If ulnar sensory and motor NCSs are normal, further investigatory studies should be performed to rule out other causes.
  • Elbow positioning should be between 70-90 degrees of elbow flexion. This provides the most accurate assessment of true nerve length. A distance of 10cm correlates best with standard published values. Values greater than 10cm my dilute a significant focal lesion and a false negative may occur.
  • Stimulation greater than 3 cm may cause submaximal stimulation as the nerve dives deep beyond this point within the flexor carpi ulnaris muscles.
  • Testing of contralateral side may be considered to compare amplitudes especially if there are symptoms, because UNE has been found to occur bilaterally in about 39%3 of cases.
  • Short segment incremental studies (inching studies) across the elbow may be used to confirm the diagnosis and to identify the precise location of entrapment.
  • Slowing in the across-elbow segment of the ulnar nerve suggests focal demyelination caused by compression/entrapment of the nerve at the elbow.

Electromyography

Abnormal spontaneous activity in ulnar-innervated hand intrinsic muscles suggests axon loss.

Early predictions of outcomes

  • The presence of atrophy, weakness, claw deformity, and/or axon loss detected by electrodiagnostic testing suggests severe nerve injury, and predicts worse outcomes.8
  • Mild neuropathy is more likely to improve with conservative treatment, while moderate/severe neuropathy may require surgery.
  • Duration of symptoms, whether greater or less than 3 months, is an early predictor of outcome after surgery, but is not predictive of longer-term outcomes after 1 year.5

Environmental

Repetitive/prolonged elbow flexion (e.g., sleeping with the elbows flexed, using the phone) and resting the elbow on hard surfaces for prolonged periods (e.g., driving or working at a desk) are risk factors for the development of UNE.

Social role and social support system

For conservative treatment options (splinting, patient education, occupational therapy), compliance with treatment requires active participation on the part of the patient and may require modifications to activities in the workplace or home.

Rehabilitation Management and Treatments

New Onset/Acute

Conservative treatment options include:

  • Patient education and activity modifications alone may be sufficient to improve symptoms in many patients with mild UNE.
  • Night splinting to prevent elbow flexion (this can be done with a formal splint or by wrapping a pillow around the extended elbow to prevent excessive elbow flexion). Night splinting should limit elbow flexion to less than 60-70 degrees of flexion from full extension.
  • Elbow padding or protective splinting to prevent external pressure on the ulnar nerve near the medial epicondyle.
  • Occupational therapy for ergonomic evaluation.
  • Conservative treatment is appropriate for mild to moderate UNE.

The best treatment for patients with mild UNE has not been well studied due to lack of trials comparing conservative treatment versus surgical intervention. A randomized controlled trial (RCT) from 2020 examined 117 patients with clinical symptoms of UNE as well as electrophysiological or sonographic confirmations of the diagnosis. Patients were randomly allocated to in situ decompression versus conservative treatment, and the results showed 85% of surgical decompression patients showed improvement at short-term follow up compared to 50% conservative treatment (P < .001), however no significant difference was observed at long-term follow up. It was concluded that surgical decompression for mild UNE resulted in faster relief of symptoms, however no long-term differences were observed.27

Chronic/stable

  • Surgical referral should be considered in confirmed cases when conservative treatment fails, or if significant weakness, atrophy, or clawing is present. There are several surgical options as follows (some of these can be further subdivided into open vs endoscopic approach)
    • Ulnar Nerve Decompression
    • Ulnar Nerve Transposition
    • Medial Epicondylectomy
  • Multiple studies including a comprehensive meta-analysis from 20111 as well as a multicenter RCT from 202126 found no significant difference in outcomes between patients treated with simple ulnar nerve decompression versus decompression with anterior transposition.An update of this meta-analysis in 2016 showed similar findings, but with a higher number of wound infections in the nerve transposition group.23
  • Surgical failure may be the result of an incorrect preoperative diagnosis, the presence of concomitant conditions, inadequate decompression, intraoperative injury to nearby nerves, postoperative nerve subluxation, or postoperative scarring or contracture.

Coordination of care

A team approach to treatment is recommended, including efficient communication between the patient, electromyographer, therapists, and surgeons. Occupational therapy may be beneficial throughout the disease process in order to address any deficits in functional activities, including activities of daily living that result from UNE, and to prevent further injury to the nerve by addressing risk factors and ergonomic issues.

Emerging/unique interventions

Local corticosteroid injection has been shown to be beneficial in the treatment of entrapment neuropathies such as carpal tunnel syndrome. However, a 2015 RCT in patients with UNE failed to show significant benefit of a local steroid injection compared to injection with placebo.7 Because of this and the limited body of evidence in support of use, the 2019 consensus statement from the European Society of Musculoskeletal Radiology states that US-guided steroid injection is feasible in patients with UNE, but not superior to placebo.18

A double-blind RCT comparing perineural dextrose injection with corticosteroid injection showed greater reduction in symptom severity between 3 and 6 months post-injection in the dextrose group. However, there was no placebo injection or control group in this study.20 A more recent prospective double-blind RCT examined the efficacy of perineural dextrose injection versus a control group in patients with ulnar neuropathy at the elbow. With the use of ultrasound guidance 1 cc of 5% dextrose was administered into the ulnar nerve at 5 different locations. The results showed improvements in pain, disability, ulnar motor nerve velocity, and ulnar nerve cross-sectional area in the dextrose group compared to the control group, especially at weeks 4 and 12 (P<0.001).24

A single RCT of 31 patients showed that postsurgical electrical stimulation improved key grip, grip strength, and estimated number of motor units on electrodiagnostic testing at 1, 2, and 3 years post-op.21 One RCT (single-blind) comparing therapeutic ultrasound and low-level laser therapy (LLLT) in the treatment of UNE. Both groups had improved electrophysiological parameters at one month without differences between the two groups. At three months, improvements persisted for the US group whereas the LLLT group only maintained changes in grip strength and latency.4 Ultrasound-guided hydrodissection is emerging as a tool for many clinicians in patients with entrapment neuropathies.19

Shortwave Diathermy Therapy

A double blind RCT investigated the efficacy of shortwave diathermy treatment compared to control group in patients with ulnar nerve entrapment at the elbow. Short wave diathermy is a modality that produces heat by converting electromagnetic energy into thermal energy. This treatment is commonly used on soft tissues and joints with the goal of reducing inflammation, swelling, pain and improving blood circulation. A total of 10 sessions of shortwave diathermy treatments were given to patients over the course of 2 weeks, as well as elbow splints and patient education to avoid symptom provoking activities. The outcomes measured showed no statistical significance between the diathermy treatment group and the control group for patients with ulnar nerve entrapment at the elbow (P > 0.05).25

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Symptoms are vital to arriving at the correct diagnosis and excluding diagnoses that may mimic UNE. Mimicking conditions include:
    • C8 radiculopathy.
    • Lower trunk or medial cord brachial plexopathy.
    • Pancoast tumor and true neurogenic thoracic outlet syndrome.
    • Motor Neuron Disease such as ALS which can present as atrophy and fasciculations in the forearm and hand muscles with preferential involvement of the thenar musculature.
  • Clues to alternative diagnosis include sensory symptoms extending proximally past the wrist into the medial forearm, an area supplied by the medial antebrachial cutaneous nerve, which originates from the medial cord of the brachial plexus, as well as neck pain radiating into the arm.
  • Nerve conduction studies of the dorsal ulnar cutaneous (DUC) nerve can help distinguish a UNE from an ulnar neuropathy at the wrist. However, many cases of UNE spare the fibers to the DUC because of selective fascicular involvement. Therefore, one can exclude ulnar neuropathy at the wrist with an abnormal DUC nerve study; however, one cannot assume that a normal DUC nerve excludes UNE.

Cutting Edge/ Emerging and Unique Concepts and Practice

N/A

Gaps in the Evidence- Based Knowledge

  • Retrospective studies attempting to see if electrodiagnostic criteria can be used to predict outcomes have shown that severe preoperative electrophysiologic findings of motor nerve involvement may be associated with poorer outcomes.8 Further prospective studies evaluating this question need to be done.
  • Prospective studies to evaluate different surgical techniques in specific sites of entrapment are needed.
  • Anti-inflammatory medications such as NSAIDs have been used to target conditions involving inflammation, however, there is limited research regarding their use in UNE.
  • Other modalities and techniques such as nerve glides/stretches have been proposed, but also have not been well studied.

References

  1. Caliandro P, La Torre G, Padau R, Giannini F, Padual L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD006839.
  2. P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2012 July 11: 7: CD006839.
  3. Radhika S, Lee YL, Low SF, Fazalina MF, Sharifah Majedah IA, Suraya A, Rajesh S, Jamari S, Tan HJ, Norlinah MI. Role of high resolution ultrasound in ulnar nerve neuropathy. Med J. Malaysia. 2015 Jun; 70(3):158-61.
  4. Kim JH, Won SJ, Rhee WI, Park HJ, Hong HM. Diagnostic cutoff value for ultrasonography in the ulnar neuropathy at the elbow. Ann Rehabil. Med. 2015 Apr; 39(2):170-5.
  5. Burns P, Kim M, Gaston G, Haase S, Hammert W, Lawton J, Merrell G, Nassab P, Yang L, Chung K. Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: A multicenter Study by the SUN Study Group. Arch Phys Med Rehabil. 2014 Apr;95(4):680-5.
  6. Baumer P, Dombert T, Staub F, Kaestel T, Bartsch AJ, Heiland S, Bendszus M, Pham M. Ulnar neuropathy at the elbow: MR neurography-nerve T2 signal increase and caliber. Radiology. 2011;260(1):199.
  7. vanVeen KE, Albias KC, Alons IM, Kerklaan JP, Siegersma MC, Wesstein M, Visser LH, Vankasteel V, Jellema K. Corticosteroid injection in patients with ulnar neuropathy at the elbow: A randomized, double-blind, placebo-controlled trial. Muscle Nerve. 2015 Sep;52(3):380-5
  8. Shi Q, MacDermid J, Grewal R, King GJ, Faber K, Miller TA. Predictors of functional outcome change 18 months after anterior ulnar nerve transposition. Arch Phys Med Rehabil. 2012 Feb; 93(2):307-12.
  9. MacDermid JC, Grewal R. Development and validation of the patient-rated ulnar nerve evaluation. BMC Musculoskeletal Discord. 2013 Apr 26; 14:146.
  10. Cartwright MS, Griffin LP, Dowlen H, Bargoil JM, Caress JB, Li ZJ, Defranzo AJ Jr, Wiesler ER, Tuohy CJ, balakrishnan N, Molnar JA, Baute V, Koman LA, Poehling GG, Walker FO. A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies. Muscle Nerve. 2015 Nov;52(5):746-53.
  11. Lyon C, Syfert J, Nashelsky J. Clinical Inquiry. Do corticosteroid injections improve carpal tunnel syndrome symptoms? J Fam Pract. 2016 Feb; 65(2):125-8.
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  13. Andrews K, Rowland A, Pranjal A, Ebraheim N. Cubital tunnel syndrome: Anatomy, clinical presentation, and management. J Orthop. 2018;15(3):832-836. doi:10.1016/j.jor.2018.08.010
  14. Haj-Mirzaian A, Hafezi-Nejad N, Del Grande F, et al. Optimal Choice of Ultrasound-Based Measurements for the Diagnosis of Ulnar Neuropathy at the Elbow: A Meta-Analysis of 1961 Examinations. AJR Am J Roentgenol. 2020;215(5):1171-1183. doi:10.2214/AJR.19.22457
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  17. Ozkan FU, Saygı EK, Senol S, et al. New treatment alternatives in the ulnar neuropathy at the elbow: ultrasound and low-level laser therapy. Acta Neurol Belg. 2015;115(3):355-360. doi:10.1007/s13760-014-0377-9
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  23. Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2016;11:CD006839. doi:10.1002/14651858.CD006839.pub4
  24. Mansiz-Kaplan B, Nacir B, Pervane-Vural S, Tosun-Meric O, Duyur-Cakit B, Genc H. Effect of Perineural Dextrose Injection on Ulnar Neuropathy at the Elbow: A Randomized, Controlled, Double-Blind Study. Arch Phys Med Rehabil. 2022 Nov;103(11):2085-2091. doi: 10.1016/j.apmr.2022.04.013. Epub 2022 Jun 9. PMID: 35690093.
  25. Bilgin Badur N, Unlu Ozkan F, Aktas I. Efficacy of shortwave diathermy in ulnar nerve entrapment at the elbow: a double-blind randomized controlled clinical trial. Clin Rehabil. 2020 Aug;34(8):1048-1055. doi: 10.1177/0269215520930062. Epub 2020 Jun 22. PMID: 32567357.
  26. Dehghan N, Nauth A, Hall J, Vicente M, McKee MD, Schemitsch EH; Canadian Orthopaedic Trauma Society. In Situ Placement Versus Anterior Transposition of the Ulnar Nerve for Distal Humerus Fractures Treated With Plate Fixation: A Multicenter Randomized Controlled Trial. J Orthop Trauma. 2021 Sep 1;35(9):465-471. doi:
  27. Pompe SM, Schreuder T, Teunissen LL, Visser LH, Beekman R. In situ decompression vs conservative treatment for mild ulnar neuropathy at the elbow. Muscle Nerve. 2020 Aug;62(2):247-253. doi: 10.1002/mus.26912. Epub 2020 Jun 10. PMID: 32369630.

Original Version of the Topic

Kevin F. Fitzpatrick, MD. Ulnar Nerve Mononeuropathy at the Elbow. 7/25/2012

Previous Revision(s) of the Topic

Thiru M. Annaswamy, MD, Dominic Jacobelli MD, UT. Ulnar Nerve Mononeuropathy at the Elbow. 8/18/2016

Lisa Williams, MD, Brandon Hassid, MD. Ulnar Nerve Mononeuropathy at the Elbow. 6/29/2021

Author Disclosures

Thiru M. Annaswamy, MD
Nothing to Disclose

Sean Furlong, DO
Nothing to Disclose