Ulnar neuropathy at the elbow (UNE) is injury to the ulnar nerve in the elbow region causing localized pain, numbness, and/or weakness in an ulnar distribution. Cubital tunnel syndrome is a subtype of UNE in which the entrapment of the ulnar nerve occurs at the humeroulnar arcade, an aponeurosis 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.
UNE may be caused by extrinsic or intrinsic compression or stretch. Common etiologic factors include repetitively or prolonged leaning elbows 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 including risk factors and primary prevention
- The incidence of ulnar neuropathy is estimated to be approximately 24.7 per 100,000 person/years.1 The incidence is higher in manual laborers1 and wheelchair users.2, 43Ulnar neuropathy at the elbow is the second most common peripheral entrapment neuropathy, behind carpal tunnel syndrome42.
- Work related factors such including working with a flexed elbow and holding direct pressure on the ulnar nerve such as “holding a tool in a position” increase risk of UNE by 3.5 times.20
- Bilateral involvement is common in patients diagnosed with UNE.3
- Systemic diseases, such as diabetes and rheumatoid arthritis, are often associated with UNE.4
- Smoking, related work experience and education level were identified as risk factors for developing UNE that required surgical treatment.21
UNE is a common neuropathy in patients with Hereditary neuropath with liability to pressure palsies, (HNPP).40,44,
Normal ulnar nerve anatomy and function:
The ulnar nerve is a nerve branch of the brachial plexus. It originates primarily from the anterior rami of the C8 and T1 spinal nerves (with some contribution from C7); these fibers travel through the lower trunk then medial cord of the brachial plexus before branching to form the ulnar nerve.
The ulnar nerve begins in the proximal axilla and travels through the upper arm near the brachial artery and median nerve. It passes through the intermuscular septum (Arcade of Struthers) in the mid-upper arm then travels along the posterior humerus into the retro-epicondylar groove postero-medial 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 III and IV.
Distally in the forearm the dorsal ulnar cutaneous and palmer cutaneous sensory nerves branches 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 the Guyon’s canal the ulnar nerve branches to supply the hypothenar muscles. 8. The ulnar nerve terminates after entering the Guyon’s canal into the deep palmer motor branch, supplying the first dorsal interosseous nerve, 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):
- Flexor Carpi Ulnaris
- Flexor Digitorum Profundus (to digits 4 and 5)
- Opponens digiti minimi
- Abductor digiti minimi
- Flexor digiti minimi
- 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 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 exit of the ulnar nerve from the flexor carpi ulnaris muscle, about 4 cm distal to the medial epicondyle, the least common site of compression.4
Of note, the ulnar nerve can also be compressed in the proximal arm in the Arcade of Struthers (aponeurotic band between the medial intermuscular septum and the medial head of the triceps brachii)36 and 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.18,32 The terminal sensory branch of the ulnar nerve is affected more frequently in UNE than the dorsal cutaneous or palmar cutaneous branches. These predilections are considered to be due to the fascicular arrangement of the ulnar nerve in the elbow region, predisposing some fascicles to be more susceptible to injury.5
Specific secondary or associated conditions and complications
Complex regional pain syndrome is a rare complication of chronic UNE.
Essentials of Assessment
The following presenting symptoms are the most common:
- Sensory changes in the dorsal and palmar surfaces of the small finger and ulnar half of the ring finger.22, 19
- Weakness or loss of coordination in the involved hand suggests motor involvement.
- There is often local pain at the medial elbow that may radiate to the hand.
Thorough sensory and motor examination should be performed of the entire involved limb with comparison to the contralateral limb.
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 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.38Wartenberg’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. This may also reproduce symptoms.
- Provocative tests (Tinel’s sign, elbow flexion test, and palpation at the elbow) have been shown to have poor sensitivities and modest specificities for UNE, and do not provide added value to routine clinical examination.29
- A thorough history of occupational and other repetitive tasks 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.28
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.
- 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.
- 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 UNE23, as well as localize the lesion to the elbow in patients with non-localizing neurophysiologic evaluations.35
- Multiple studies16,17,34 have shown that comparing cross sectional area on ultrasound of the affected ulnar nerve to normative values or a proximal site on the ulnar nerve47 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.31 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).37 Another study using ultrasound evaluation demonstrated a twofold occurrence of anatomic abnormalities, such as the presence of an anconeous 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%).39
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.18
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 and can be used to localize the lesion of the ulnar nerve to the region of the elbow.22
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.9,27
- A large review of outcomes10 suggests that mild neuropathy is more likely to improve with conservative treatment, while moderate/severe neuropathy may require surgery.24
- 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.18
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
Available or current treatment guidelines
Dellon’s review10 uses a staging system to predict outcomes with treatment:
- Mild neuropathy has about a 50% success rate with conservative treatment.
- Moderate or severe neuropathy has poorer outcomes with conservative treatment and likely requires surgery.
- A large meta-analysis of 6 RCTs in 2012 could not conclude based on imaging, clinical, or electrophysiologic characteristics, the best treatment option for UNE.15
Treatment guidelines for work-related UNE recommend surgical exploration and release if: conservative management has failed, the condition interferes with work or activities of daily living, and the diagnosis has been established.
At different disease stages
Conservative treatment options include:
- Patient education and Activity modifications; These interventions alone may be sufficient to improve symptoms in many patients with mild UNE.11
- 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.24, 32
- 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-analysis12 found no significant difference in outcomes between patients treated with simple ulnar nerve decompression versus decompression with nerve transposition.25 An update of this meta-analysis in 2016 showed similar findings, but with a higher number of wound infections in the nerve transposition group.52 Wade et al in a 2020 systematic review found that in situ decompression was more effective than transposition.51
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.13
Coordination of care
A team approach to treatment requires excellent 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.
Patient & family education
- Family education is vital to the success of conservative treatments, and postoperative compliance can influence the success of a surgical procedure.
- One study showed that patient education alone may be adequate for the treatment of some patients with mild UNE.11
Local corticosteroid injection has been shown to be beneficial in the treatment of entrapment neuropathies such as carpal tunnel syndrome. 33 However, a 2015 RCT in patients with UNE failed to show significant benefit of a local steroid injection compared to injection with placebo.26 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.46 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.49A single RCT of 31 patients by Power et al 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.50One 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.45Ultrasound-guided hydrodissection is emerging as a tool for many clinicians in patients with entrapment neuropathies.48
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.
- Although weakness in the ulnar-innervated forearm muscles may occur in UNE, it is rare in mild or moderate cases because of elective fascicular involvement.
- 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
See the Imaging section for details on the use of MRI and ultrasound in the evaluation of UNE.
Gaps in the Evidence- Based Knowledge
- There is very limited evidence in the literature for conservative treatment options in UNE, and there exists no management guidelines for selection of treatment options for patients with UNE. Additionally, there are no RCTs comparing surgical vs non-surgical intervention for UNE. The existing trials compare efficacy of different surgical treatments without comparison to conservative management.
- 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.27 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.
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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
Nothing to Disclose
Brandon Hassid, MD
Nothing to Disclose