Cubital Tunnel Syndrome: Therapy Treatment

Evaluation Notes for Clinicians

Patient Rated Outcome Measures

→ Administer at evaluation, re-evaluation, and discharge.

• Quality of Life Patient Reported Outcome Measure

  • The PROMIS Global 10

• Patient Rated Ulnar Nerve Evaluation (PRUNE)

  • MDC = 7.2 points¹

• Patient Rated Wrist Hand Evaluation (PRWHE)

  • MCID = 24 points²

• QuickDASH

  • MDC = 11 points³

• Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE v 2.0)

  • MCID = 3.1-3.7⁴

Observations^5-8

• General posture → rounded shoulders, head forward and palms facing backwards at rest suggest proximal weakness. Please also note scapula position on ribcage.

• Note any visible or palpable ulnar nerve subluxation over the medial epicondyle while taking the elbow through full ROM.

  • Note: The ulnar nerve travels posterior to the medial epicondyle under the Osborne ligament (the cubital tunnel).

• Advanced symptoms of CuTS:

  • Wasting of the hypothenar and interosseous muscles of the hand (Note any observations of decreased palmar thickness).

  • Ring and small finger clawing (Clawhand deformity, aka Duchenne sign).

  • Decreased fine motor skills.

Upper Quarter Screen

→ Ulnar nerve arises from C8-T1

• Dermatomes, Myotomes, and Reflexes

• Ulnar innervated muscles:⁵

  • Extrinsics

    • Anterior Forearm: Flexor carpi ulnaris, flexor digitorum profundus of the SF and RF

  • Intrinsics

    • Thenar: Adductor pollicis

    • Hypothenar: Opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis, palmaris brevis

    • Fingers: Dorsal/palmar interossei, third and fourth lumbricals

• Ulnar nerve sensory distribution:

  • Palmar cutaneous branch → Medial aspect of hand

  • Dorsal cutaneous branch → Dorsal aspect of the SF and medial half of the RF

  • Superficial branch → Palmar aspect of the SF and medial half of the RF

Neurological Assessment

• Ulnar Nerve Tension (ULTT3)

• Sensory Testing: While it is important to assess each digit, testing the radial and ulnar sides of the 5th digit provides information exclusively on ulnar nerve function.^{6, 8}

  • Semmes West Monofilaments to assess light touch^{6, 9}

• Price for Full Semmes West starting at $155

• Price for Semmes West Minikit starting at $52

• Static 2-Point Discrimination → Pressure should be provided using just the weight of the instrument on the longitudinal orientation of each digit.

• According to a study that investigated expert consensus on the diagnosis of CuTS, a majority of hand and upper-extremity surgeons agreed that a 2-Point Discrimination > 6mm indicates CuTS.⁶

• Price starting at $49 on Amazon

Range of Motion⁸

Norms available via the American Academy of Orthopaedic Surgeons. Please ensure measurements are obtained for both sides of the body to inform goal setting versus solely relying on norms. To facilitate inter-rater reliability, please refer to the standardized goniometric measurement techniques from the American Society of Hand Therapists (ASHT.org member cost $100, non-member $145).

• Cervical ROM¹⁰

• Shoulder ROM all planes

• Elbow ROM all planes

• Forearm ROM all planes

• Wrist ROM all planes

  • Note any decreased wrist flexion given FCU ulnar-innervation

• Opposition

  • Pay attention to SF opposition to assess opponens digiti minimi

• Screen thumb ROM

• Flexion/extension of digits 2-5

  • Note any flexion lag that may be caused by weakness of the intrinsic muscles

• Abduction/adduction of digits 2-5

  • To assess interossei function

  • Document any observation of Wartenberg Sign^7-8

• Observe intrinsic plus position (MP flexion and IP extension)

  • To assess interossei and lumbrical function

Strength Testing

• Manual Muscle Testing (MMT)

  • Wrist flex/extend

  • Elbow flex/extend

  • Shoulder flex/abduct/ER/IR

  • Evidence suggests resisting specific ulnar-innervated muscles when examining CuTS:^5-6

• Grip strength bilaterally with the elbow in extension and flexion.^{6, 8} Extended arm grip strength measurements will not put tension on the ulnar nerve and will provide information about proximal strength.

  • Grip Dynamometer costs approximately $350 on Amazon

  • Check out our Grip Strength blog post for more information on additional equipment, resources, and current research!

• Pinch strength bilaterally to assess interosseous and lumbrical function.^6-7

  • Pinch Gauge costs approximately $130 on Amazon

  • Palmar/Tripod/3-point pinch

  • 2-point pinch

  • Lateral pinch

    • Note: Weakness of the adductor pollicis can cause decreased lateral pinch strength, potentially indicating ulnar nerve involvement.

    • Document observations of Froment’s Sign.^7-8

      • Observe IP joint flexion of the thumb due to compensation of the flexor pollicis longus (median nerve innervation) for adductor pollicis and flexor pollicis brevis weakness.

      • Jeanne’s Sign → thumb MCP joint extension/hyperextension may occur while testing for Froment’s sign.⁷

Special Tests

• Scratch-Collapse Test ^{6-8, 11-12} at ulnar nerve compression sites in the upper extremity:^{5, 13}

  • Osborne’s Ligament/Cubital Tunnel Retinaculum

  • Between the two heads of the FCU

    • Note: This is the most common site of ulnar nerve compression⁵

  • Additional common compression sites for differential diagnosis:

    • Medial Intermuscular Septum

    • Arcade of Struthers

    • Deep flexor/pronator aponeurosis

    • Guyon’s Canal

  • Specificity = 75%, Sensitivity = 37%, Accuracy = 58%¹¹

• Elbow Flexion Test^5-7

  • Document the number of seconds timed before sensory symptoms appear. Upon re-evaluation, use that information to gauge progress if the time lengthens.

  • Specificity = 40-99%, Sensitivity = 36-93%¹⁴

• Shoulder Internal Rotation Test¹⁵

  • Introduced by Ochi et al. (2011) as an alternative to the Elbow Flexion Test.

  • Specificity = 100%, Sensitivity = 80% by 10 seconds¹⁵

• Tinel’s sign at the medial elbow^5-7

  • Positive sign → numbness/tingling in ulnar nerve sensory distribution

  • Specificity = 53%, Sensitivity = 62%¹⁴

• Cross-Finger Test

  • While this test is not well studied, the inability to cross the middle finger over the index finger may suggest weakness of the dorsal interosseous muscles.⁷

• Egawa’s Sign also suggests weakness of the interosseous muscles.^/7

Differential Diagnoses^5-7

• Ulnar nerve compression in Guyon’s canal

  • Note: Compression at Guyon’s canal would not affect the ulnar-innervated extrinsic musculature (FCU and FDP of SF/RF) as they are innervated proximal to this structure.

• Thoracic outlet syndrome

• Cervical radiculopathy

• Medial epicondylitis

• Medial epicondyle osteophytes

• Pancoast tumor

• Brachial plexopathy

• Martin-Gruber anastomosis considerations

  • Nerve-related anatomical variations may cause clinical presentations that differ from typical sensory and motor innervation. Anastomoses between branches of the ulnar and median nerves are possible at several sites within the upper extremity. Awareness of these variations will aid in identifying the most beneficial interventions for recovery.¹⁶ This anatomical study can provide more information.

Goal Bank for Club Members

Each goal is intended as a starting point. The functional motivation behind each goal should be identified collaboratively with the client.

• Patient will report a decrease in (PRUNE / PRWHE / QuickDASH / PROMIS UE v 2.0) outcome score to (at least MDC / MCID) demonstrating increased activity tolerance in affected functional tasks like *** without symptom increase within 3 weeks.

• Patient will demonstrate improved tactile acuity in the ulnar nerve sensory distribution by scoring < 6 mm on the 2-Point Discrimination test, facilitating participation in functional tasks like [manual dexterity tasks, holding objects, etc] within 6 weeks.

• Patient will demonstrate increased [PIP/DIP] joint extension of the [SF/RF] to *** within 6 weeks to improve performance in functional tasks like [grasping a cup/pushing a door/etc].

• Patient will demonstrate increased grip strength to *** to improve occupational performance in [patient-specific I/ADL] within 6 weeks.

  • Note: Right-handed individuals are typically 10% stronger on their dominant side, while left-handed individuals tend to have bilaterally identical grip strengths due to living in a right-handed world.

• Patient will identify 1-3 activity modifications that decrease symptoms to increase activity tolerance in [patient-specific I/ADL] within 2 weeks.

• Patient will appropriately demonstrate one pain management technique in the clinic within 3 weeks to increase activity tolerance in [patient-specific I/ADL].

Treatment Notes for Club Members

Some research suggests that conservative management for ulnar nerve conditions is indicated when symptoms are less than 6 months old, sensory testing is within normal limits, and there is no visible muscle wasting.⁷ According to a systematic review, the most common therapy duration for the conservative management of CuTS was 3 months, with an optimal treatment time between 6 and 12 weeks.¹⁷

Aerobic Warm Up

→ For endorphin release, and to assist synovial fluid excretion.

• A systematic review suggests the potential for physical exercise to promote physical neuropathy function by facilitating axonal regeneration.¹⁸

Nighttime Orthosis

→ To reduce ulnar nerve inflammation.

• The goal of a nighttime orthosis is to prevent tight elbow flexion, which tensions the ulnar nerve. Moderate evidence demonstrates that orthotic use and/or activity modifications may provide symptom relief in patients with mild-moderate CuTS.^19-20 Moreover, one prospective study following individuals with mild-moderate CuTS reported a higher likelihood of preventing surgical intervention after 3 months of rigid nighttime orthosis use at 45º of elbow flexion.²⁰

  • Recommended to immobilize the elbow in 45º of extension with the forearm in neutral rotation using a custom-fabricated orthosis. 5 Trial for 6-12 weeks in patients with mild-moderate CuTS.¹⁷ Pre-fabricated options are also available:

    • One prefab option for approximately $50: Hely & Weber

    • One prefab option for approximately $35: Pil-O-Splint Elbow Support

      • Note that this option tends to keep the elbow in a more extended position than 45º

    • A more affordable option to try at home: Folded towel technique → wrap a standard bath towel lengthwise around the extended elbow and secure with duct tape.

  • While it is worthwhile to trial a nighttime orthosis, as this is the ideal option to prevent tight elbow flexion during sleep, many patients may not find it functional. It is important to work with the patient to find solutions that work for them and increase compliance, such as making adjustments to orthoses or reviewing sleep positioning.

Manual Therapy

→ Recommended neuropathic approach to improve space, movement, and blood flow for the nerve.²¹

• Instrument Assisted Soft Tissue Mobilization (IASTM)

• Recommended Multi-Tool from Hawkgrips can be used on full body.

  • Cost: $595.00

• Cupping therapy

  • Silicone cupping set found on Amazon for approximately $30.

  • Hand pump rigid cupping set found on Amazon for approximately $30.

• Soft tissue mobilization has demonstrated improvements in nerve conduction, pain, and function of the median nerve in carpal tunnel syndrome.²²

• Joint Mobilizations → Mechanical Interface Approach following the nerve pathway.^23-24

  • The Mechanical Interface Approach is defined as strategies to mobilize the tissues and structures that surround a nerve in order to impact its ability to move and function.

  • Consider including cervical (first rib, scalenes), brachial plexus (first rib, clavicle, pec minor), elbow, forearm, and wrist/hand.

    • Wrist mobilizations

    • Elbow distraction

  • Consider techniques like Pin & Stretch, Strain Counterstrain, Strumming, Myofascial Release

Neuromuscular Re-Education

→ To address coordination, proprioception, posture and motor planning.

Neurodynamic Techniques

• Ulnar nerve mobilization to reduce upper quadrant pain²⁵ and improve nerve conduction, discriminative sensation, and upper limb function.²⁶

• Different neurodynamic techniques (e.g. slider vs tensioner nerve glides) produce different mechanical effects on the nerve.

  • Sliding techniques result in a larger excursion of the nerve while putting less strain on it, compared to tensioning techniques. Slider techniques may be a more appropriate option for acute conditions.²⁷

  • Tensioner techniques tend to be more symptomatic than slider techniques; therefore, patients may tolerate slider techniques better earlier in the rehabilitation process. By discharge, the patient should tolerate both.

• This video demonstrates slider and tensioner ulnar nerve glides

  • Note: Skip to 2:27 in the video for ulnar nerve glides. Not all patients will tolerate this end range, especially when they first begin these exercises. The nerve glide techniques may need to be performed in the middle range of available motion to begin.

Coordination Challenges

• Tendon glides → correct compensations present due to weakened ulnar-innervated musculature.

• In-hand manipulation targeting palmar translation and ulnar storage (see below).

Sensory Re-Education

• Stereognosis challenges:

  • Have the patient locate objects in a sensory bin with their vision occluded. To incorporate the ulnar nerve, have the patient then store the items in their ulnar palm to facilitate palmar translation and ulnar storage.

• Exposure to/identification of various textures, ranging from soft to more abrasive (e.g., silk versus sandpaper).

Proprioception

• Implement putty exercises while paying close attention to the force required to manipulate the putty.

• Isolate and resist ulnar-innervated muscles.

Functional Postural Strengthening

• Scapular stabilization and postural control:

  • Bruggers Exercise

  • Shoulder external rotation (with shoulder adducted)

    • Perform with or without a resistance band. Therabands can be purchased on Amazon starting at approximately $13.

Core Exercises

Self-Care Home Management

• Educating patients on symptom provocation and activity modifications has been shown to improve CuTS symptoms.^{5, 17, 19, 28}

• Inform patients that prolonged or repetitive elbow flexion can cause that “kink” in the ulnar nerve, which can worsen symptoms. Work with the patient to modify activities and identify adaptive equipment to manage symptoms and support occupational participation. Activity modifications may include:^{7, 20}

  • Adjusting their work station (e.g. the height of the keyboard and mouse) to allow the elbows to rest in a position less than 90º of flexion.

  • Using a headset/airpods/speaker phone while taking long phone calls (rather than holding the phone up to their ear).

  • While driving, adjust the seat position to allow the elbows to remain open/avoid tight flexion.

Incorporate Functional Tasks

→ Based on patient goals and affected ADLs.

• Practice activity modifications for patient-identified I/ADLs in the clinic to promote carry-over at home

• Engage ulnar-innervated musculature to improve participation/activity tolerance in functional activities

  • Putty exercises for:

    • Grip strength (intrinsic hand muscles)

    • Finger abduction (dorsal interossei)

    • Finger adduction (palmar interossei)

    • Intrinsic plus position (third and fourth lumbricals + interossei)

    • Lateral pinch (adductor pollicis)

    • Ulnar deviation → utilize a puttycise large knob (for approximately $18 on Amazon) to challenge FCU

  • Theraputty can be purchased on Amazon for approximately $18

Additional Pain Management Tools

• Modalities: Pulsed signal therapy,⁵ ultrasound, low-level laser therapy²⁹

• Elbow pads, approximately $20 on Amazon, to reduce compression

• Kinesiotape, approximately $15 on Amazon, along the nerve pathway

Home Program

• Prioritize 1-3 exercises to enhance patient adherence to the home program.

Patient Education on Disease Pathology

• Conservative management of CuTS should include patient education on disease pathology to prepare for identifying activity modifications with the patient to minimize symptom provocation.^{5, 7}

• It can help to describe the nerve as a hose. When it gets a kink in it, or is compressed, the water does not flow smoothly anymore, and it stops working efficiently. The length of time that the nerve is compromised matters as well. If you drive over a hose, it recovers pretty quickly. However, if you park on a hose all winter, it takes longer to recover.

The ulnar nerve originates from the neck, and it travels through the elbow and wrist joints before ending in the hand. Movements at the elbow and wrist can cause a “kink” in the ulnar nerve. In the case of CuTS, a bent elbow can cause the kink that damages the ulnar nerve. Compressing the nerve by using armrests or leaning on your elbow on the edges of a desk/table can also cause damage.

• Hand and Upper Extremity Rehabilitation: A Practical Guide 4th Edition is a useful reference text for treating the upper extremity

  • Starting at $79.55 on Amazon

• American Society for Hand Therapists (ASHT.org)

  • Annual Membership is $275

• The American Society of Hand Therapists outlined several novice hand therapist resources, including content related to anatomy, orthotic fabrication, how-to video series, and more.

• Hand Therapy Academy

• Article for review of anatomy: Andrews, K., Rowland, A., Pranjal, A., & Ebraheim, N. (2018). Cubital tunnel syndrome: Anatomy, clinical presentation, and management. Journal of Orthopaedics, 15(3), 832-836. Redirecting

• Reference the Indiana Hand to Shoulder Center’s Diagnosis and Treatment Manual for Physicians & Therapists, 5th Edition for post-operative protocols