Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome and Ulnar Neuritis |
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Introduction
Ulnar nerve problems can occur in many situations: occupational overuse, injury, high performance such as athletics and sports (e.g. baseball, tennis). The two main mechanisms are compression at the cubital and recurrent dislocation with elbow movements, causing a friction irritation and neuritis. I've scanned them with ultrasound and, in severe cases, the nerve can be twice its normal size. Clinical Features - pain and/or pins and needles, and sometimes swelling, in the posteromedial elbow area - neurological symptoms in the field of the nerve: along the medial forearm, little finger and hypothenar eminence - provocation with arm and hand movements: gripping, elbow flexion/extension - common in factory workers and baseball pitchers - reproduction of symptoms with: palpation of the nerve at the elbow and the ulnar neurodynamic test - sometimes it's worse at night because the patient sleeps on a flexed elbow which compresses the nerve - Tinel's sign can be abnormal: tapping the nerve produces pins and needles along its course into the little finger - neurological deficit (sensation loss) in the little finger and sometimes along the medial forearm - checking the neck and shoulder reveals little or, if it does show abnormality, the double crush syndrome might be a problem - unloading the nerve reduces symptoms: passive elbow extension, wrist flexion and scapular elevation - compression test is abnormal: sustained elbow flexion and you can add pressure with your thumb because this makes it more sensitive (Novak et al 1994). Treatment - multifactorial and influenced entirely by assessment findings - neural unloading - progressive neural movements and loading (see video below) - taping to stop the elbow flexing at night. This can give dramatic relief if the patient wakes up a lot because of a flexed elbow. - balancing movement and rest so the nerve has time to recover from offending movements - myofascial and neural massage techniques to the flexor carpi ulnaris and associated soft tissues. The patient can learn these from the clinician and do these when necessary. - self stretches of flexor carpi ulnaris - modifying movement technique: style, frequency, speed and intervals, to reduce provocation - surgery to decompress or relocate the nerve (if this is an option medically) and the patient does not respond to conservative management. The nervous system is continuous over long distances so problems in one area may affect others. You may need to test and treat MSK and neurodynamics along the system, such as muscles and nerves from the arm to the neck. -- Reference Novak C, Lee G, Mackinnon S, Lay L 1994 Provocative testing for cubital tunnel syndrome. The Journal of Hand Surgery, 19(5), 817–820. DOI:10.1016/0363-5023(94)90193-7 |
Ulnar Nerve Mobilisations and Exercises: Progressions - low to high.
Movement Control and NeurodynamicsNeurodynamic tests and movement control are often dealt with as distinct problems: "Correct the movement problem and mobilise the nerves" in separate techniques or exercises.
But the body doesn't move one system at a time and we need to consider functional diagnoses and treatments that treat both aspects simultaneously. It's how the body really moves and this treatment reproduces real-time integration much more accurately. Below is a description of a few aspects to deal with when someone has arm pain associated with abnormal shoulder movement and neurodynamics in the brachial plexus and ulnar nerve. Controlling Shoulder Movement When the Ulnar Nerve and Brachial Plexus are a ProblemIt can be important to protect nerves whilst moving the musculoskeletal (MSK) system. The nervous system is similar to the MSK system - move it or lose it - in which quality may be important. Too much force - stretch and compression - can irritate or damage nerves and not enough can cause them to lose function (Rezvyakov et al 2018).
You can show the patient how to move without compressing their nerves, e.g. controlling shoulder dynamics for the ulnar nerve and brachial plexus as part of management of arm pain. -- Reference Rezvyakov et al 2018 Morphological study of myelinated fibers of the sciatic nerve in mice after space flight and readaptation to the conditions of earth gravity. Physiology 482: 174–177. DOI: 10.1134/S0012496618050101 |
Tight Muscles, Ulnar Nerve and Brachial Plexus
Muscle contraction during neurodynamic tests is normal, maybe to prevent the nerves undergoing excessive elongation - protection.
When abnormal, contraction can be excessive, particularly when someone is in pain and has movement dysfunctions. So we can give the patient exercises that specifically target their unique movement dysfunction in relation to neurodynamics.
When abnormal, contraction can be excessive, particularly when someone is in pain and has movement dysfunctions. So we can give the patient exercises that specifically target their unique movement dysfunction in relation to neurodynamics.
Michael Shacklock
December 9, 2020.
December 9, 2020.