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CUBITAL TUNNEL SYNDROME

Introduction

Cubital tunnel syndrome is an upper extremity compression neuropathy represented by entrapment of the ulnar nerve at the level of the elbow. Initially, symptoms include pain in the medial aspect of the elbow and pain and paresthesias in the ring and small fingers. Patients complain of numbness, partiularly in the little finger.  As the disease progresses, patients become increasingly clumsy and weak, with eventual constant numbness and atrophy of the unlnar intrinsic muscles of the hand. Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity after carpal tunnel syndrome.

Related Anatomy*

  • Medial epicondyle
  • Anconeus Epitrochlearis
  • Olecranon>
  • Cubital tunnel retinaculum
  • Arcade of Struthers
  • Arcuate ligament
  • Medial collateral ligament
  • Osborne fascia
  • Proximal flexor profundus arch
  • Ulnar nerve

* See labeled mages below.

Incidence and Related Conditions

  • Potential etiologies: repetitive use of vibrating tools, playing musical instruments, tourniquet use, intra-operative malpositioning, cubitus varus and valgus deformity, adhesions, burns and heterotopic ossification, space-occupying lesions, osteoarthritis, excessive pressure on the posterior medial elbow and/or excessive hyperflexion posturing of the elbow.

Differential Diagnosis

  • C8 or T1 radiculopathy
  • Thoracic outlet syndrome
  • Pancoast tumor
  • Double crush syndrome
  • Distal ulnar tunnel syndrome (ulnar entrapment in Guyon's canal)
  • Golfer's Elbow (Medial epicondylitis)
ICD-10 Codes

  • CUBITAL TUNNEL SYNDROME

    Diagnostic Guide Name

    CUBITAL TUNNEL SYNDROME

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    CUBITAL TUNNEL SYNDROME G56.22G56.21G56.23

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Cubital Tunnel Syndrome landmarks
    Cubital Tunnel Syndrome landmarks
  • Cubital Tunnel Syndrome Anatomic Relations-Ulnar Nerve Under fascia below epicondyle and posterior to intramuscular septum edge
    Cubital Tunnel Syndrome Anatomic Relations-Ulnar Nerve Under fascia below epicondyle and posterior to intramuscular septum edge
Symptoms
Numbness (paresthesias) in 4th and 5th fingers
Pain - medial elbow area, ulnar hand and 4th and 5th fingers
Night pain
Clumsiness
Hand weakness
Muscle atrophy in the hand
Numbness on dorsal ulnar aspect of the hand
Painful clicking at the olecranon groove (ulnar nerve subluxation)
Typical History

Most patients will first present with sensory loss and pain in the ring and little fingers. Sometimes, patients have a history of trauma to the medial side of the elbow. Occasionally, patients will complain of clicking on the medial side of the elbow caused by subluxation of the ulnar nerve over the medial epicondyle. Over time, patients will report problems with grasping objects, feeling clumsy and marked weakness. Symptoms are exacerbated by elbow flexion, resting the elbow on hard surfaces, hyperflexion elbow exercises and shoulder abduction.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Technique for taking a cubital tunnel view
    Technique for taking a cubital tunnel view
  • Cubital Tunnel view with no arthritis. 1.Cubital tunnel (Olecranon Groove); 2.Olecranon; 3.Proximal Radius; 4.Distal Humerus
    Cubital Tunnel view with no arthritis. 1.Cubital tunnel (Olecranon Groove); 2.Olecranon; 3.Proximal Radius; 4.Distal Humerus
  • Cubital Tunnel view with arthritis. 1. Cubital tunnel (Olecranon Groove); 2. Olecranon; 3. Proximal Radius; 4. Distal Humerus Arrow - osteophyte compressing ulnar nerve
    Cubital Tunnel view with arthritis. 1. Cubital tunnel (Olecranon Groove); 2. Olecranon; 3. Proximal Radius; 4. Distal Humerus Arrow - osteophyte compressing ulnar nerve
  • Elbow MRI Cross Section - Note medial posterior position of the Ulnar Nerve
    Elbow MRI Cross Section - Note medial posterior position of the Ulnar Nerve
Treatment Options
Conservative
  • In patients with early ulnar nerve compression:
    • Avoid maximum elbow flexion
    • Avoid resting elbow on hard surfaces
    • Avoid repetitive hyperflexion elbow exercises
    • Non-steroidal anti-inflamatory drugs (NSAIDs)
    • Night elbow extension splinting
Operative
  • After symptoms progress and/or become constant:
    • In situ decompression of the ulnar nerve (currently favored procedure for non-subluxating compressed ulnar nerves)
      For ASSH's Hand-e Surgical Video of LRTI Minimally Invasive Method for Cubital Tunnel Decompression by Hausman:
    • Transposition (subcutaneous, intramuscular, submuscular) of the ulnar nerve
      For ASSH's Hand-e Surgical Video of Cubital Tunnel Release with anterior transposition by Werntz:
    • Medial epicondylectomy
Treatment Photos and Diagrams
  • Cubital Tunnel-single arrow Osborne's ligament & double arrow E. Muscle
    Cubital Tunnel-single arrow Osborne's ligament & double arrow E. Muscle
  • Cubital Tunnel Syndrome- Note edge of intramuscular Septum. A section of this should be removed when doing anterior transposition of the ulnar nerve
    Cubital Tunnel Syndrome- Note edge of intramuscular Septum. A section of this should be removed when doing anterior transposition of the ulnar nerve
  • Cubital Tunnel Syndrome: Double arrow was the point of constriction caused by Osborne's ligament and proximal FCU sheath. Proximal swelling consistent with "Pseudoneuroma" of ulnar nerve entrapment
    Cubital Tunnel Syndrome: Double arrow was the point of constriction caused by Osborne's ligament and proximal FCU sheath. Proximal swelling consistent with "Pseudoneuroma" of ulnar nerve entrapment
  • Cubital Tunnel Syndrome - Subcutaneous transposition of the ulnar nerve
    Cubital Tunnel Syndrome - Subcutaneous transposition of the ulnar nerve
  • Cubital Tunnel Syndrome - Intramuscular Transposition
    Cubital Tunnel Syndrome - Intramuscular Transposition
  • Cubital Tunnel Syndrome - Submuscular Transposition
    Cubital Tunnel Syndrome - Submuscular Transposition
  • Ulnar neurolysis using arthroscope
    Ulnar neurolysis using arthroscope
  • Arthroscopic view of ulnar nerve and fascia
    Arthroscopic view of ulnar nerve and fascia
  • Carposcope Ulnar Neurolysis Incision
    Carposcope Ulnar Neurolysis Incision
  • Carposcope Ulnar Neurolysis Incision open
    Carposcope Ulnar Neurolysis Incision open
  • Carposcope Ulnar Neurolysis Tools - Guide top left & Scope bottom right
    Carposcope Ulnar Neurolysis Tools - Guide top left & Scope bottom right
  • Carposcope Ulnar Neurolysis- Nerve exposed and scope being placed in subcutaneous tissue superficial to fascia
    Carposcope Ulnar Neurolysis- Nerve exposed and scope being placed in subcutaneous tissue superficial to fascia
  • Carposcope Ulnar Neurolysis- Dilator separating fascia from underlying ulnar nerve
    Carposcope Ulnar Neurolysis- Dilator separating fascia from underlying ulnar nerve
  • Carposcope Ulnar Neurolysis- Guide separating fascia from underlying ulnar nerve
    Carposcope Ulnar Neurolysis- Guide separating fascia from underlying ulnar nerve
  • Carposcope Ulnar Neurolysis-Guide separating fascia from underlying ulnar nerve
    Carposcope Ulnar Neurolysis-Guide separating fascia from underlying ulnar nerve
  • Carposcope Ulnar Neurolysis- Guide separating fascia from underlying ulnar nerve while forked knife (arrow) begins to cut fascia
    Carposcope Ulnar Neurolysis- Guide separating fascia from underlying ulnar nerve while forked knife (arrow) begins to cut fascia
  • Carposcope Ulnar Neurolysis- Tortuous nerve
    Carposcope Ulnar Neurolysis- Tortuous nerve
  • Carposcope Ulnar Neurolysis- Severely constricted ulnar nerve
    Carposcope Ulnar Neurolysis- Severely constricted ulnar nerve
  • Carposcope Ulnar Neurolysis- Severely constricted ulnar nerve after release - note residual nerve deformity
    Carposcope Ulnar Neurolysis- Severely constricted ulnar nerve after release - note residual nerve deformity
  • Carposcope Ulnar Neurolysis- Incision closed
    Carposcope Ulnar Neurolysis- Incision closed
CPT Codes for Treatment Options

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Common Procedure Name
Cubital tunnel release (also submuscular transfer)
CPT Description
Neurolysis and/or transposition ulnar nerve at elbow
CPT Code Number
64718
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy

RECOMMENDED HAND SURGEON THERAPY ORDERS

  • Dressing management as needed
  • Edema control
  • Patient education
  • Progressive active range of motion exercises within week 1
  • Wound management after sutures out - massage
  • Begin strengthening exercises at 6 weeks
  • Scar conformer splinting if scar hypertrophic
  • Work hardening if needed

REVIEW OF THERAPIST INTERVENTIONS FOR CUBITAL TUNNEL SYNDROME

  • Therapy for non-operative patient may include part-time day splinting with splint sleeves, elbow pads worn backwards and task modification to avoid aggravating tasks.
  • Splinting may include night splinting with elbow splints or elbow towel wraps to avoid full flexion while asleep.
  • Stretching exercises, nerve glides, taking breaks, ice x 10 minutes intermittently during task performance (especially heavy tool use or repetitive posturing and task performance).

STATUS POST CUBITAL TUNNEL RELEASE

Early hand therapist assistance and intervention (first week post-op):

  • Dressing assessment and changing
  • Edema control – encourage elevation, encourage early gentle finger ROM, watch for RSD/CRPS signs.
  • Patient education – teach signs of infection,avoid maceration of surgical site, encourage smoke free recovery, avoid excessive exercise to minimize scarring.
  • At week 1, finger tendon glides and thumb glides should be reviewed for controlled AROM of fingers and thumb (avoid power flexion with wrist palmar flexed).
  • At week 2, steri-strips may be present to approximate the surgical site to prevent excessive tension on the new scar.  Instruct patient to keep dry for 24 hours after suture removal.
  • Initiate light compressive sleeves to keep edema and scar under control.
  • At week 2-3, scar management, scar massage with vitamin E oil / thick vitamin E cream in light circular motions with moderate pressure, 3-4 minutes twice daily.  Introduce scar conformer.
  • At week 2-3, wrist AROM in all planes within a pain free range (flexion/extension and UD/RD)
  • Educate patient in desensitization techniques to minimize post-operative hypersensitivity.
  • Initiate a kid friendly preloaded battery power toothbrush to encourage desensitization as necessary, 3-5 minute sessions several times per day.
  • At week 4, educate the patient to limit strengthening tasks, lifting and heavy use until 6 weeks post-op.
  • Encourage finger food tasks, in-hand manipulation and coin stacking to optimize intrinsic function, and integrate putty exercises for home program.
  • Progress to full unrestricted AROM and PROM of fingers, thumb, wrist and elbow while activity re-integration.
  • Continue scar management and introduce a scar conformer such as silicone based products, e.g. image.
  • At 6 weeks, initiate light strengthening as tolerated with little or no pain as tolerated.
  • Reintegrate full use of the arm and hand into life.
  • At 6-8 weeks, progress strengthening and work hardening/work simulation as needed.  Sports may be resumed at this time.
  • Assess and provide education for ergonomics, core strengthening.
  • May require figure 8 splint (anti-claw) if intrinsic interossei dysfunction exists.
  • Review intrinsic muscle exercises with putty for home.

*Wound healing may be prolonged in diabetic patients and smokers

Complications
  • Failure to relieve symptoms
  • Decompression: nerve injury, neuroma
  • Transposition: ischemic neuritis, long-term elbow instability
  • Recurrent ulnar nerve irritation/compression
  • Pain at the osteotomy site
  • Infection
  • Failure to relieve symptoms
  • Medial antebrchial cutaneous nerve injury
  • Ulnar nerve subluxation
Outcomes
  • Conservative: usually only short-term relief of symptoms with subsequent surgery frequently required.
  • Operative: satisfactory outcomes have been reported after decompression alone and more extensive procedures.
YouTube Video
Cubital Tunnel Syndrome
Key Educational Points
  • Cubital tunnel syndrome is the second most common compression neuropathy in the upper extremity.
  • Cubital tunnel syndrome causes numbness in the ring and little fingers.  In chronic cubital tunnel syndrome hand weakness becomes the most troublesome symptom.
  • A rare but important component of the cubital tunnel differential diagnosis is ALS ( Amyotrophic Lateral Sclerosis or Lou Gehrig's Disease). This confussion can occur because 30% of ALS patients present with upper extremity weakness. ALS can be distinquished from Cubital Tunnel Syndrome by the absence of sensory loss, tongue fasciculations, and the involvement of multiple nerves in ALS patients.
  • The most common complication of endoscopic cubital tunnel release is hematoma.
  • To identify weakness of high ulnar innervated muscles, compare FDP II & III (median nerve innervated) to FDP IV & V (ulnar nerve innervated) during simultaneous muscle testing of the two pairs.
References

New articles

  1. Bacle G, Marteau E, Freslon M, et al. Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months. Orthop Traumatol Surg Res 2014;100(4Suppl):S205-8. PMID: 24721248
  2. Noland SS, Fischer LH, Lee GK, et al. Essential hand surgery procedures for mastery by graduating plastic surgery residents: a survey of program directors. Plast Reconstr Surg 2013;132(6):977-84. PMID: 24281644
  3. Adams S, Isaacs J.  Amyotrophic Lateral Sclerosis. J Hand Surg 2010; 35A:841-845. PMID: 19942362

Reviews

  1. Rinkel WD, Schreuders TA, Koes BW, Huisstede BM. Current evidence for effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, instability, or bursitis of the elbow: a systematic review. Clin J Pain 2013;29(12):1087-96. PMID: 23985778
  2. Kroonen LT. Cubital tunnel syndrome. Orthop Clin North Am 2012;43(4):475-86. PMID: 23026463

Classics

  1. Pechan J, Julis I. The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of the cubital tunnel syndrome. J Biomech 1975;8(1):75-9. PMID: 1126976
  2. Wadsworth TG, Williams JR. Cubital tunnel external compression syndrome. Br Med J 1973;1(5854):662-6. PMID: 4692712

HAND THERAPY REFERENCES

  1. Cannon, et al. (2001).  Diagnosis and Treatment Manual for Physicians and Therapists, Upper extremity Rehabilitation (4thed).  The Hand Rehabilitation Center of Indian
  2. Mackin, Callahan, Skirven, Schneider, and Osterman, (2002). Rehabilitation of the Hand and Upper Extremity, 1, (5th ed). St Louis, MO: Mosby Year Book, Inc.
  3. Cooper, (2014). Fundamentals of Hand Therapy; Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, (2nd ed). Mosby, imprint of Elsevier Inc. Stanley and Tribuzi. (1992).  Concepts in Hand Rehabilitation.  F. A. Davis Company
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