Ulnar Neuritis

Ulnar neuritis is the inflammation or irritation of the ulnar nerve, leading to sensory and motor disturbances along its distribution. It commonly presents with pain, numbness, tingling and weakness in the ring and little fingers. It may also affect the forearm and hand. If untreated, ulnar neuritis can lead to muscle atrophy, trophic changes in tissues, and significant functional impairment.

 

Delayed-Onset Ulnar Neuritis (DOUN)

Delayed-Onset Ulnar Neuritis refers to the development of new symptoms affecting the ulnar nerve or the worsening of pre-existing symptoms during the postoperative rehabilitation phase, despite the patient having normal ulnar nerve function before surgery. It may result from surgical positioning, prolonged immobilization or changes in biomechanics during recovery.

 

Causes of Ulnar Neuritis

 

Signs and Symptoms of Ulnar Neuritis

Symptoms (What the patient experiences)

• Paroxysmal pain in the elbow, forearm and hand.
• Decreased sensation on the ulnar side of the hand and forearm.
• Cold sensitivity in the affected hand.
• Weakness in grip strength leading to difficulty performing fine motor tasks (e.g., buttoning clothes).
• Symptoms worsen with prolonged elbow flexion (e.g., holding a phone, sleeping with bent elbows).

Signs (What can be observed or elicited by a clinician):

• Loss of sensation or decreased sensitivity in the 4th and 5th fingers.
• Weakness in finger adduction and abduction (4th and 5th fingers).
• Visible difficulty with fine motor coordination.
• Atrophy of the hypothenar eminence and intrinsic hand muscles.
• Progressive muscle wasting, leading to a “claw hand” deformity in severe cases.
• Pain or discomfort exacerbated by palpation or pressure over the ulnar nerve’s pathway (e.g., cubital tunnel or Guyon’s canal).

Trophic Changes:

1. Bluish discoloration of the skin.
2. Swelling or puffiness in the affected area.
3. Excessive sweating.
4. Ulcerations in advanced stages due to poor nerve supply.

 

Diagnosing Ulnar Neuritis

Diagnostic Findings for Ulnar Neuritis

1. X-Ray

• Bone spurs or osteophytes near the medial epicondyle.
• Narrowing or deformity of the cubital tunnel.
• Evidence of arthritis or joint degeneration.
• Fractures or dislocations affecting the elbow or wrist.
• Mass lesions like ganglion cysts (may require further imaging for confirmation).

2. Nerve Conduction Studies (NCS)

• Slowed Conduction Velocity: Reduced speed of nerve signals across the cubital tunnel or Guyon’s canal.
• Conduction Block: Significant delay or absence of nerve signal transmission at the site of compression.
• Prolonged Latency: Increased time for the nerve impulse to travel, particularly in sensory or motor fibers.
• Reduced Amplitude: Decreased nerve signal strength, suggesting axonal degeneration or severe compression.

3. Electromyography (EMG)

• Fibrillation Potentials: Indicates active denervation in affected muscles, such as the hypothenar muscles or interossei.
• Positive Sharp Waves: Suggests ongoing nerve damage or axonal loss.
• Reduced Motor Unit Recruitment: Demonstrates weakened nerve input to the muscles.
• Chronic Changes: Large, polyphasic motor unit potentials due to reinnervation after prolonged nerve damage.
• Specific Muscle Abnormalities: Involvement of ulnar-innervated muscles like the first dorsal interosseous or abductor digiti minimi.

Differential Diagnoses for Ulnar Neuritis

• Cervical radiculopathy (C8-T1)
• Thoracic outlet syndrome
• Brachial plexopathy
• Guyon’s canal syndrome
• Medial epicondylitis (golfer’s elbow)
• Diabetic peripheral neuropathy
• Cubital tunnel syndrome
• Elbow arthritis
• Wrist ganglion cyst
• Syringomyelia
• Multiple sclerosis
• Radial or median nerve entrapment (for overlapping symptoms)
• Polyneuropathy.
• Motor neuron disease (e.g., ALS)

 

Physiotherapy Management of Ulnar Neuritis

The physiotherapy management of ulnar neuritis focuses on reducing symptoms, restoring function and preventing recurrence through tailored, evidence-based rehabilitation techniques. 

Rehabilitation Goals

• Nerve Health: Stimulate regeneration and improve blood flow to the ulnar nerve.
• Prevention of Complications: Avoid adhesions, scarring, joint stiffness and contractures.
• Motor Recovery: Strengthen weakened muscles, restore motor function and normalize motor skills for daily and occupational tasks.
• Compensatory Strategies: Develop adaptive methods to improve functionality during recovery.

Management Strategies

A. Patient Education

Posture Modification:

• Avoid prolonged elbow flexion (common during phone use or sleeping).
• Refrain from leaning on elbows, especially on hard surfaces.

Activity Modification:

• Reduce repetitive elbow and wrist motions.
• Introduce ergonomic tools like wrist supports.

B. Pain and Inflammation Control

Physiotherapy Techniques:

• Electrophoresis: With medications like novocaine and lidase.
• Phonophoresis: Using hydrocortisone for inflammation.
• Magnetic Therapy: Reduce inflammation and enhance nerve healing.
• Electromyostimulation: Improve muscle function and nerve conduction.
• Transspinal Pulsed Magnetic Fields: Target inflamed nerve roots.

Electrotherapy Modalities:

• TENS, therapeutic ultrasound, or laser therapy for pain relief and inflammation reduction.

Cryotherapy and Heat Therapy:

• Ice: For acute inflammation.
• Heat: For chronic cases with muscle tightness.

C. Nerve Mobilization

These exercises involve controlled movements that guide the ulnar nerve through its natural pathway, minimizing adhesions and promoting healthy nerve mobility. Gliding exercises are categorized into sliding and tensioning techniques:

Sliding Techniques

Focus on moving the nerve back and forth within its sheath without increasing tension. This creates a "flossing" effect, sliding the nerve within its sheath.

Examples:

1. Start with elbow flexion and wrist extension (to shorten the nerve).
2. Gradually move to elbow extension and wrist flexion (to lengthen the nerve).

Tensioning Techniques

Apply a controlled stretch to the ulnar nerve along its pathway. This technique is more intense than sliding and aims to gradually increase the nerve's tolerance to stretch and load.

Example:

1. Start with the shoulder abducted, elbow extended, and wrist and fingers extended.
2. Progressively increase tension by gently tilting the head away from the affected side.
3. Release the tension by returning to the starting position.

D. Manual Therapy

• Soft Tissue Mobilization: Relieve tension in the elbow, forearm, and wrist muscles (e.g., flexor carpi ulnaris).
• Joint Mobilization: Improve mobility of elbow and wrist joints if stiffness is present.

E. Strengthening and Conditioning

Hand Muscles:

• Exercises targeting interossei and hypothenar muscles, such as squeezing a soft ball or finger abduction with resistance.

Forearm Muscles:

• Wrist curls, reverse curls and pronation-supination exercises.

Grip Strengthening:

• Therapy putty or grippers.

F. Stretching Exercises

Focus on flexibility in muscles like:

• Flexor carpi ulnaris.
• Flexor digitorum profundus and superficialis.

G. Postural and Ergonomic Training

• Teach patients neutral wrist and elbow alignment.
• Optimize workplace ergonomics (desk height, keyboard positioning).

H. Functional Training and ADL Re-education

• Gradual reintegration of activities like writing, typing, or tool use to enhance hand coordination.

Splinting or Bracing

• Night Splinting: To maintain slight elbow extension during sleep.
• Daytime Bracing: To reduce strain on the wrist or elbow during activities.

Integration of Occupational Therapy

• Focus on labor-specific tasks and functional recovery, complementing physiotherapy’s focus on basic physical restoration.

Postoperative Care (if surgery is needed)

Common surgical options include ulnar nerve decompression or transposition. Postoperative protocols are tailored to the procedure:

Simple Decompression:

• Immediate full range of motion allowed.

Subcutaneous Anterior Transposition:

• Restricted elbow extension (up to 30°) for the first week.

Postoperative Rehabilitation:

Use of Continuous Passive Motion (CPM):

• Initiated immediately after surgery to maintain elbow mobility.
• Breaks of 5 minutes every hour to reduce strain.
• Can be continued for ~4 weeks at home for optimal recovery.

Challenges in Rehabilitation

• Lack of standardized and effective rehabilitation protocols for ulnar neuritis.
• Limited efficacy of generic hand and finger exercises.
• To address these issues, physiotherapy emphasizes personalized rehabilitation plans that align with the nerve's physiology and recovery needs.