Cubital tunnel syndrome is caused by compression of the ulnar nerve at the elbow, which can cause numbness, tingling, and weakness in the fourth and fifth fingers. It is often caused by repetitive elbow bending or prolonged pressure on the elbow. Diagnosis involves testing for sensory and motor function deficits in the ulnar nerve distribution and provocative tests that reproduce symptoms. Treatment may include splinting, anti-inflammatory medications, corticosteroid injections, physical therapy, and surgery if conservative measures fail.

3.  The cubital tunnel is made up in the bones in elbow and
forearm muscles which run across the elbow joint.
Ulnar nerve passes through the tunnel to supply
sensation of fingers and information to the muscles to
help move your hand.

4.  Cubital tunnel syndrome (CBTS) is a peripheral nerve compression
syndrome. It is a condition caused by pressure on the ulnar nerve at
the elbow. Nerves carry messages between the brain, spinal cord,
and body parts. When a nerve is compressed, it cannot function
properly.
 Cubital Tunnel Syndrome is the second most common nerve
entrapment syndrome, after Carpal Tunnel Syndrome.
The Ulnar Nerve carries signals for sensation in one half of our ring
finger and our small finger and to our muscles that perform fine hand
movements. Individuals with Cubital Tunnel Syndrome have
difficulty handling objects and performing gripping
motions. Individuals may feel pain, numbness, and a “tingly”
sensation, similar to when the “funny bone” is hit. When the" funny
bone " is hit, the odd feeling is actually caused by the Ulnar Nerve.

5.  Ulnar nerve Arises from C8-T1
◦ pierces intramuscular septum at arcade of Struthers 8 cm proximal to
the medial epicondyle as it passes from the anterior to posterior
compartment of the arm
◦ enters cubital tunnel
 Cubital tunnel
◦ roof
 formed by FCU fascia and Osborne's ligament (travels from the medial
epicondyle to the olecranon)
◦ floor
 formed by posterior and transverse bands of MCL and elbow joint capsule
◦ walls
 formed by medial epicondyle and olecranon

6.  Ulnar nerve entrapment can occur at 5 possible sites around
the elbow:
- Arcade of Struthers (approximately 10cm proximal to the
medial epicondyle)
- Medial intermuscular septum (runs from the arcade to the
epicondyle)
- Medial epicondyle
- Cubital tunnel (retinaculum)
- Deep flexor pronator aponeurosis (about 5cm distal to the
epicondyle)
Out of all the 5 sites, the cubital tunnel is the most common
site for entrapment.

7.  cubitus varus or valgus deformities
 medial epicondylitis
 burns
 elbow contracture release

8.  Symptoms occur when the nerve becomes restricted by
pressure within the tunnel. The reason is usually
unknown, but possible causes can include: swelling of
the linning of the tendons, joint dislocation, fracture or
arthritis. Fluid retention during pregnancy can also
sometime cause swelling in the tunnel. Symptoms are
made worse by keeping the elbow bent for long periods
of time.

9. Symptoms include:
 pain or paresthesias
 Numbness
 clumsiness of the hand as a result of weakness, hyperesthesia,
 muscle cramping
 dull ache after activity or rest
 aggravation of symptoms with activity and pain which may radiate
up the forearm to the elbow and as far as the shoulder.
 Tingling sensation in the arm, hand and/or fingers of the affected
side
 The symptoms are often felt during the night. But may be noticed
during the day when the elbow is bent for long periods of time.
 In severe cases sensation may be permanently lost and some of the
muscles in the hand and base of the little finger may reduce in size.

10.  People with diabetes mellitus are at higher risk for any kind
of peripheral neuropathy, including ulnar nerve entrapments.
 Cubital tunnel syndrome is more common in people who spend long
periods of time with their elbows bent, such as when holding a
telephone to the head. Flexing the elbow while the arm is pressed
against a hard surface, such as leaning against the edge of a table, is a
significant risk factor. The use of vibrating tools at work or other
causes of repetitive activities increase the risk, including throwing a
baseball.
 Damage to or deformity of the elbow joint increases the risk of
cubital tunnel syndrome. Additionally, people who have other nerve
entrapments elsewhere in the arm and shoulder are at higher risk for
ulnar nerve entrapment. There is some evidence that soft tissue
compression of the nerve pathway in the shoulder by a bra strap over
many years can cause symptoms of ulnar neuropathy, especially in
very large-breasted women.

11.  There are many factors which can lead to cubital tunnel
syndrome. They include:
 Mechanical factors such as stretching of, friction on or
compression of the ulnar nerve
 Direct trauma or other space occupying lesions, repetitive
elbow flexion/extension, repetitive overhead activities,
traction, subluxation of the ulnar nerve from the ulnar
groove, metabolic disorders, congenital deformities,
synovial cysts, anatomical irregularities, arthritis, joint
inflammation, and occupational/athletic factors.

12.  head injuries with upper extremity flexion contractures
 > 40 years old
 overhead throwing activities
 work which involves prolonged periods of elbow flexion
such as holding a telephone
 resting elbows on a hard surface
 obesity
 Symptoms can sometimes be associated with other
conditions such as: osteoarthritis, rheumatoid arthritis and
other diseases, for example: diabetes mellitus, haemophilia.
 Symptoms can be aggravated by alcoholism, obesity and
smoking.

13. Depending on the duration and progression of the
disorder, patients with cubital tunnel syndrome will
present with similar but specific symptoms. Primary
symptoms are typically medial elbow pain or aching in
the forearm. Numbness and tingling may also be
present in the 4th and 5th digits, the ulnar side of the
dorsum of the hand and the hypothenar eminence. The
patient may also report non-painful snapping or
popping during active and passive flexion and extension
of the elbow. A Wartenberg sign (abduction of the fifth
digit due to weakness of the third palmar interosseous
muscle) may be present. Active and passive ROM may
not be decreased. The ulnar nerve may be enlarged or
palpable and tender in the groove. On observation, there
may be atrophy of the intrinsic muscles of the hand,
which is often not noticed by the patient, with abnormal
claw posture of the 4th and 5th fingers.

14.  An accurate diagnosis includes assessing the following:
sensory changes in the ulnar nerve distribution (½ of
the 4th digit and entirety of the 5th), pain, atrophy of
the intrinsic muscles of the hand innervated by the
ulnar nerve, neural provocation test of the ulnar nerve,
and sparing of the flexor carpi ulnaris muscle.
 Tests used to confirm the diagnosis of cubital tunnel
syndrome are those linking ulnar neuropathy and the
elbow. These tests should evoke provocative signs as a
reaction to confirm the syndrome, such as: elbow
flexion reproducing symptoms, positive Tinel’s sign
tested at the elbow or a sign of instability, for example
snapping of the ulnar nerve over the medial epicondyle
with elbow flexion.

15.  Elbow Flexion Test
 Pressure Provocative Test
 Tinnel Sign
 Scratch Collapse Test

16.  Froment sign :
◦ compensatory
thumb IP flexion by
FPL (AIN) during key
pinch
 compensates for the
loss of MCP flexion
by adductor pollicis
(ulna n.)
 adductor pollicis
muscle normally
acts as a MCP
flexor, first
metacarpal
adductor, and IP
extensor

17.  Jeanne sign :
◦ compensatory
thumb MCP
hyperextension
and thumb
adduction by EPL
(radial n.) with
key pinch
 compensates for
loss of IP
extension and
thumb adduction
by adductor
pollicis (ulna n.)

18.  Wartenberg sign
◦ persistent small
finger abduction and
extension during
attempted adduction
secondary to weak
3rd palmar
interosseous and
small finger
lumbrical

19.  Masse sign
◦ palmar arch flattening and loss of ulnar hand
elevation secondary to weak opponens digiti quinti
and decreased small finger MCP flexion

20.  EMG / NCV :
◦ conduction velocity <50 m/sec across elbow
◦ low amplitudes of sensory nerve action potentials
and compound muscle action potentials
CT Scan
MRI

21. Treatment may include:
 Conservative treatment
• Medication
• Physiotherapy
 surgery

22.  NSAID’s: to reduce soft tissue swelling.
 Corticosteroid injection: to relieve
inflammation and pressure on the radial
nerve.

23. -Rest
-Night splint
-Joint mobilization
-ROM exercises
-Stretching
-Strengthening / Stabilization
-Manual Therapy
-Nerve Gliding(3times/day)
-Postural Training
-Modalities (ice, ultrasound, phonophoresis,
iontophoresis)
-Functional training / Work place
modification/activity modification

24.  Simple decompression
 Medial epicondylectomy
 Anterior transposition

25. Most patients diagnosed with cubital tunnel
syndrome have advanced disease (atrophy,
static numbness, weakness) that might reflect
permanent nerve damage that will not recover
after surgery. When diagnosed prior to
atrophy, weakness or static numbness, the
disease can be arrested with treatment. Mild
and intermittent symptoms often resolve
spontaneously.

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