Cubital Tunnel Syndrome

When you hit your “funny bone” you are actually hitting a nerve behind your elbow. Occasionally this nerve becomes compressed or irritated resulting in pain and numbness and tingling in the arm and hand. This is sometimes mistakenly thought to be coming from the neck.

Often times the effects of this nerve being compressed are more subtle with just a gradual loss of strength and dexterity in the fingers but minimal pain. Therefore, there is often a delay in individuals seeking treatment for this resulting in permanent nerve damage and muscle loss in the hand.

Cubital Tunnel Syndrome: What is it?

Cubital tunnel syndrome is a compressed or irritated nerve behind the elbow. The cubital tunnel is made up of the elbow bones and the tissue that covers the muscles around the elbow. The ulnar nerve which supplies feeling to the ring and small fingers and strength to many of the small muscles in the hand runs through this tunnel. If there is not enough space for the nerve as it runs through this tunnel then symptoms begin to develop.

Symptoms: What does Cubital Tunnel Syndrome feel like?

Cubital tunnel syndrome most commonly results in numbness and tingling or a pins-and-needles sensation in the ring and pinky fingers and along the inner aspect of the hand or forearm.
Occasionally people feel an electrical sensation running from the elbow down into their fingers.
There may be sudden pain or a “funny bone” sensation with just light bumping of the elbow.
Weakness or loss of strength is another common complaint and people may find themselves dropping things.
Difficulty with fine motor activities such as buttoning a shirt or a sense of clumsiness is common as cubital tunnel syndrome progresses.
If left untreated, muscle loss or wasting of the little muscles in the hand develops, particularly the muscles between the thumb and index finger on the back side of the hand.

Causes

Cubital tunnel syndrome is usually not the result of a single factor. Often there may not be a clearly identified cause. In most cases there is a combination of multiple factors that contribute to the increased pressure or irritation of the nerve.

Anatomic factors: some individuals have an extra muscle behind the elbow that can compress the nerve. A broken elbow, arthritis or a ganglion cyst from the elbow can result in less space for the nerve. In some individuals the nerve moves and snaps back and forth over the bone on the inside of the elbow and can become irritated as a result.

Activity factors: prolonged or repetitive bending of the elbow as in holding a phone or sleeping with the elbows tightly bent can cause compression of the nerve. Pressure on the elbow such as on the arm rests of a chair can also irritate the nerve.

Evaluation: How is Cubital Tunnel Syndrome diagnosed?

Your doctor will ask you questions about your symptoms and what makes your symptoms more bothersome. Several physical exam tests can be done to assess whether you may have this condition, such as tapping along the course of the nerve behind the elbow or flexing your elbows.

X-ray: sometimes X-rays of your elbow are done to assess for conditions such as arthritis that may be contributing to your symptoms.
Electrodiagnostic tests: nerve conduction and electromyogram (EMG) studies measure electrical impulses in your muscles and across your nerves and can show if you have cubital tunnel syndrome or other conditions in which nerves can be pinched, as well as measuring how severe it is. More severe cubital tunnel syndrome often warrants more aggressive or prompt treatment.
MRI: occasionally an MRI of the elbow can be done to assess for structural compression of the nerve by the elbow.

Treatment

Non-operative treatment

Activity changes: avoiding prolonged elbow flexion positions or taking breaks to stretch and change positions can help to lessen symptoms. Using a phone head set can be helpful as well.
Night splinting: wearing an elbow pad, wrapping the elbow with a towel and ace wrap or wearing a rigid splint on the elbow at night can help to prevent the extreme elbow flexion position that often causes people to wake up with numbness and pain in the hand.
Therapy: instruction in nerve gliding exercises, stretching or therapeutic ultrasound may be recommended for mild cubital tunnel syndrome.
Non-steroidal anti-inflammatory drugs (NSAIDs): anti-inflammatories such as ibuprofen or naproxen can help reduce the discomfort associated with cubital tunnel syndrome .but have not been shown to permanently treat it.

Surgery

If symptoms are more severe or they continue despite the above treatments, surgery may be recommended.
There are several surgeries that can be done for cubital tunnel syndrome including:
- In situ decompression: the tight tissue the compresses the nerve is released
- Subcutaneous ulnar nerve transposition: the nerve is released and moved to the front side of the elbow beneath the skin
- Submuscular ulnar nerve transposition: the nerve is released and moved to the front side of the elbow beneath the muscles on the inner part of the arm
- Medial epicondylectomy: the nerve is released and the bony prominence adjacent to the nerve is removed
Your surgeon can discuss the pros and cons of each of these and which may be recommended in your situation.
Risks of surgery are low and include (but are not limited to) nerve, tendon, or blood vessel damage, infection or wound healing problems, painful scar tissue and incomplete nerve recovery with ongoing numbness or weakness in the hand and fingers.

Recovery: What Can Be Expected?

Surgery to release the cubital tunnel is an outpatient procedure meaning patients go home the same day as surgery. Light use of the arm and hand is often permitted immediately after surgery. An elbow or wrist splint or sling may be used to rest the arm.

Sutures are often absorbable and a follow-up appointment is usually scheduled between one to two weeks after surgery to ensure the wound is healing appropriately. Therapy may be recommended at this point to begin gentle range of motion and strengthening exercises. Once the incision is healed activities can be gradually advanced as tolerated.

If you had constant numbness in the fingers before surgery it can take months for that to recover. If you had lost muscle in the hand that often does not fully recover but should not continue to worsen.

It is possible but uncommon for cubital tunnel symptoms to come back after surgery.

Frequently asked questions about Cubital Tunnel Syndrome

How do I know if I have cubital tunnel syndrome?

If you are having numbness or tingling in your ring and small finger or are losing strength or muscle mass in your hand, you may have cubital tunnel syndrome. An evaluation with an orthopedic or hand surgeon can be helpful to determine if your symptoms are due to a compressed ulnar nerve.

How do you know the numbness and weakness is coming from cubital tunnel syndrome and not from my neck or shoulder?

The physical exam maneuvers can be useful in identifying where the nerve is pinched and the electrodiagnostic or EMG tests more definitively demonstrate where a nerve is pinched by measuring how the nerves conduct electricity and how the muscles supplied by the nerve are functioning. When the nerve is pinched at the elbow it conducts electrical signals slower than areas where it is not compressed.

Can cubital tunnel syndrome get better on its own?

Yes. Mild cubital tunnel syndrome often responds to simple treatment with activity modification avoiding prolonged elbow flexion, anti-inflammatories, and simple exercises such as nerve gliding exercises.

I know someone who had cubital tunnel surgery and didn’t get any better after surgery – what are the chances of that?

Cubital tunnel syndrome is often painless and therefore many people do not seek treatment until they have lost significant muscle strength and mass in the hand. This is often the sign of permanent nerve damage and may not get better after surgery. Surgery can still be useful for preserving the function and strength that you do have and preventing further loss of function but this is often less satisfying than regaining your normal strength or feeling. Pain relief is most predictable after surgery. Sensation can continue to improve for months after. But muscle loss, if it is present before surgery is usually permanent to some degree. Nerve recovery depends on your age, how long you have had the symptoms, how severely the nerve has been compressed, and on your other medical conditions such as diabetes or smoking.

Can you have surgery on both sides at the same time?

This can make daily life activities difficult so usually one side is done at a time.

How long will I be out of work after surgery?

This depends on the nature of your work and the willingness of your work to accommodate light duty. Low demand activities such as clerical work can often be resumed within days after surgery. Higher demand activities can be resumed as tolerated often between 4 to 6 weeks after surgery.

How soon can I drive after cubital tunnel surgery?

You should not drive while taking narcotic pain medications. Once you are off the prescription pain medications and your pain is manageable to allow you to safely operate a vehicle you may resume driving. Often this is within a week or two after surgery.

How painful is cubital tunnel surgery?

Everyone’s pain threshold and pain experience is different. Many people manage the pain with just acetaminophen (Tylenol) and/or ibuprofen (Advil) after surgery. If stronger pain pills are required they are usually just needed for the first few days after surgery.

What if I don’t treat my cubital tunnel syndrome?

If cubital tunnel syndrome is left untreated there is a risk of permanent nerve damage leading to loss of strength, muscle function in the hand, and loss of feeling in the ring and small fingers. If you have constant numbness where the fingers never fully wake up or feel normal or you feel you are losing muscle mass in the hand you should seek treatment more urgently. The longer it is left untreated, the longer it takes for the nerve to recover and the lower the likelihood of a full recovery.

Physicians

The following physicians specialize in the treatment of Cubital Tunnel Syndrome:

R. Blake Curd, MD

Jason L. Hurd, MD

David B. Jones Jr., MD

Keith M. Baumgarten, MD

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