Cubital Tunnel Syndrome

Cubital Tunnel Syndrome (CuTS) is a compressive neuropathy of the ulnar nerve as it passes through the cubital tunnel at the elbow. It is the second most common peripheral nerve compression syndrome in the upper extremity after carpal tunnel syndrome, with an incidence of 24.7 cases per 100,000 people and a prevalence of 2–6% in the general population.

CuTS can result from conditions such as osteoarthritis, rheumatoid arthritis, diabetes mellitus and Hansen’s disease. The cubital tunnel is anatomically composed of the retrocondylar groove (partially covered by the Osborne ligament), the humeroulnar arcade and the deep flexor/pronator aponeurosis. If untreated, CuTS may lead to functional impairment and permanent nerve damage, significantly affecting daily activities, work and recreational tasks.

Classification of Cubital Tunnel Syndrome

Cubital Tunnel Syndrome (CuTS) can be classified into two types based on Sunderland’s classification.

Anatomy & Sites of Compression

The ulnar nerve can be compressed at multiple anatomical sites along its course through the elbow region. The five principal sites of compression, listed from proximal to distal, include:

1. Arcade of Struthers (~10 cm proximal to medial epicondyle) - a fibrous band from the medial head of the triceps to the medial intermuscular septum. Compression is rare but can occur due to thickening.
2. Medial Intermuscular Septum - the nerve transitions from the anterior to posterior arm compartment here. Thickening or fibrosis may cause compression.
3. Condylar (Retrocondylar) Groove - a shallow groove behind the medial epicondyle. Repetitive elbow flexion, trauma or ulnar nerve subluxation can cause irritation.
4. Cubital Tunnel Retinaculum (Osborne’s Ligament) - the most common site of compression, forming the roof of the cubital tunnel between the medial epicondyle and olecranon. Aggravated by inflammation, hypertrophy or increased tunnel pressure.
5. Deep Flexor-Pronator Aponeurosis (~5 cm distal to medial epicondyle) - the nerve passes beneath this aponeurosis into the forearm. Hypertrophy or fibrosis may cause compression here.

Causes & Risk Factors of Cubital Tunnel Syndrome

Causes

Compression at key anatomical sites - arcade of struthers, medial intermuscular septum, medial epicondyle, cubital tunnel, deep flexor-pronator aponeurosis.

• Primary (Idiopathic) CuTS  - no structural abnormalities.
• Secondary CuTS - due to trauma, degenerative changes, systemic diseases (e.g., rheumatoid arthritis), lipomas, ganglion cysts or inflammation.

Risk Factors

• Repetitive movements  - frequent elbow flexion and extension.
• Prolonged elbow flexion - holding the elbow bent for long periods (e.g., phone use, sleeping).
• Direct pressure - leaning on the elbow for extended periods.
• Elbow trauma or fractures - altered anatomy increasing nerve compression.
• Thickened or tight tissues - scar tissue, cysts or muscle hypertrophy.
• Cubitus valgus deformity - abnormal elbow alignment straining the nerve.
• Swelling or fluid retention - conditions like arthritis reducing cubital tunnel space.
• Occupational activities - jobs or sports requiring repetitive elbow movement.
• Lifestyle factors - obesity and smoking increase the risk.

 

Clinical Presentation of Cubital Tunnel Syndrome

Key Symptoms

• Numbness & Tingling - paresthesia in the ring and little fingers, worsened with elbow flexion.
• Weakness -- reduced grip strength and fine motor skill impairment.
• Pain - inner elbow, forearm and hand discomfort, varying in intensity.
• Clumsiness - tendency to drop objects and difficulty with precise hand movements.
• Burning Sensation - "Pins and needles" or burning discomfort in the forearm and hand.
• Sensory Loss - diminished touch, temperature or pain perception in the ulnar side of the hand.
• Pain Worsening at Night - symptoms intensify when sleeping with a bent elbow.

Advanced Signs

• Muscle Atrophy - wasting of hypothenar and intrinsic hand muscles, causing a hollowed appearance.
• Clawing of Fingers - ulnar claw deformity affecting the fourth and fifth fingers in severe cases.

 

Diagnosing Cubital Tunnel Syndrome

Differential Diagnosis

• Cervical Radiculopathy (C8/T1)
• Thoracic Outlet Syndrome (TOS)
• Guyon’s Canal Syndrome
• Medial Epicondylitis (Golfer’s Elbow)
• Ulnar Neuropathy at the Wrist
• Brachial Plexopathy
• PeripheralNeuropathy (e.g., Diabetes-related)
• Motor Neuron Disease (e.g., ALS)
• Ulnar Nerve Tumors or Ganglion Cysts
• Syringomyelia or Spinal Cord Lesions

 

Physiotherapy Management of Cubital Tunnel Syndrome

Physiotherapy plays a crucial role in conservative management by reducing symptoms, improving function and preventing progression. 

1. Goals of Physiotherapy Treatment

• Alleviate pain and paresthesia.
• Reduce nerve compression and irritation.
• Restore normal movement and function.
• Improve strength and flexibility of surrounding musculature.
• Prevent recurrence through ergonomic and postural modifications.

2. Conservative Physiotherapy Management

A. Activity Modification

• Avoid repetitive elbow flexion & prolonged pressure on the ulnar nerve (e.g., leaning on elbows while working).
• Modify work tasks to minimize stress on the elbow and wrist (e.g., using a headset instead of holding a phone).
• Maintain proper sleeping positions (elbow in a slightly extended position) to reduce nighttime nerve compression (Lund & Amadio, 2019).

B. Splinting & Bracing

• Night Splints - maintaining the elbow in a 30°-45° extension reduces ulnar nerve stress (Kang et al., 2020).
• Functional Bracing - custom elbow braces may prevent excessive flexion in daily activities.

C. Pain and Symptom Management

• Cryotherapy (Ice therapy) - spplied for 10-15 minutes to reduce local inflammation and pain.
• Heat Therapy - useful before exercise to relax muscles and improve mobility.
• Kinesiology Taping - supports the medial elbow and may improve proprioception (Vicenzino et al., 2020).

3. Physiotherapy Exercises for CuTS

A. Nerve Gliding (Neurodynamic) Techniques

These help reduce adhesions and improve mobility of the ulnar nerve. Techniques should be performed with caution to prevent overstretching.

Ulnar Nerve Glides ("Flossing")

1. Start with the elbow bent and wrist extended.
2. Slowly straighten the elbow while bending the wrist.
3. Perform 10 repetitions, 2-3 times daily (Schmid et al., 2013).

Ulnar Nerve Mobilization with Shoulder Abduction

• Extend the fingers and wrist while slowly abducting the shoulder.
• Maintain a gentle nerve stretch, not inducing pain.

B. Stretching and Strengthening Exercises

• Forearm Flexor Stretch

Extend the elbow and wrist, using the opposite hand to apply gentle pressure on the fingers. Hold for 20-30 seconds, repeat 3 times.

• Forearm Extensor Stretch

Similar to the flexor stretch but reverse the process(wrist flexed).

• Grip Strengthening with Therapy Putty or Stress Ball

It enhances intrinsic hand muscle strength, improving overall hand function.

• Resisted Wrist and Finger Extension/Flexion

Use light resistance bands to strengthen wrist stabilizers.

• Shoulder and Postural Strengthening

Scapular stabilization exercises (e.g., wall slides, prone T/Y lifts) improve proximal stability, reducing compensatory strain at the elbow (Park et al., 2019).

4. Manual Therapy

• Soft Tissue Mobilization & Myofascial Release

It helps reduce muscle tightness around the medial elbow. Focus on flexor carpi ulnaris and pronator teres muscles.

• Joint Mobilization (Elbow & Wrist)

 Reduces stiffness and improves nerve mobility.

• Dry Needling

 It may reduce muscle hypertonicity around the medial epicondyle (Boyd et al., 2021).

5. Electrophysical Modalities

• Therapeutic Ultrasound - pulsed ultrasound (0.8–1.0 W/cm² for 5–7 min) may reduce inflammation (Baysal et al., 2006).
• Low-LevelLaser Therapy (LLLT) - shows potential pain relief benefits but lacks robust evidence (Chang et al., 2020).
• TENS(Transcutaneous Electrical Nerve Stimulation) - applied over the medial elbow to modulate pain perception.

Note: Electrophysical agents should complement, not replace, active rehabilitation.

 

6. Ergonomic and Postural Modifications

• Workstation Adjustments

Keyboard and mouse positioning to reduce prolonged elbow flexion along with forearm support pads to prevent direct pressure on the medial elbow.

• Correcting Forward Head & Rounded Shoulder Posture

Maintaining proper scapular positioning reduces distal nerve tension (Ferguson & Rempel, 2022).

7. Lifestyle Modifications

• Maintain a healthy weight to reduce metabolic stress on nerves.
• Quit smoking, as nicotine can impair blood flow and delay healing.
• Dietary supplements (Vitamin B12, Omega-3s) may support nerve health (Sharma et al., 2021).

8. Return to Work & Sport Considerations

• Gradual return to activities with modification of grip and elbow positioning.
• Athletes (e.g., baseball pitchers, golfers) should undergo sport-specific rehab for throwing mechanics.
• Occupational therapy may help in workplace adaptations.

 

Physiotherapy alone may not be sufficient if:

1. Persistent pain, weakness or numbness despite 6–12 weeks of therapy.
2. Severe muscle atrophy or hand dysfunction (e.g., claw hand deformity).
3. Electrodiagnostic studies show worsening nerve conduction.

Surgical options include:

• In Situ Decompression (for primary CuTS).
• Subcutaneous/Submuscular Ulnar Nerve Transposition (for severe cases).
• Medial Epicondylectomy (rarely performed).

Outcomes

• Significant pain relief and reduction in numbness/tingling.
• Improved muscle strength and hand function.
• Enhanced quality of life due to restored nerve function.
• Addresses the root cause of nerve compression, promoting long-term recovery.

Complications 

• Infection at the surgical site.
• Hematoma (blood accumulation).
• Scarring. 
• Temporary or permanent sensory or motor deficits.
• Possible worsening of symptoms in rare cases.

Prevention and Management:

• Careful surgical planning and precise technique to minimize risks.
• Postoperative care and monitoring to detect and manage complications early.
• Open communication between patients and healthcare providers about potential risks and benefits.