Last week I introduced peripheral entrapment neuropathies and how they can manifest and present as hidden, debilitating conditions affecting various regions of the body and the extremities. One of the key issues regarding peripheral entrapment neuropathies is the fact that they typically have multiple originating causes. This week we will address a painful condition known as Ulnar Nerve Entrapment or Cubital Tunnel Syndrome.
At the elbow, the ulnar nerve courses through a tunnel of tissue known as the cubital tunnel that runs along the inside of the elbow. The area where the nerve travels at the inside(medial) aspect of the elbow is frequently known as the “Funny Bone” and if it is bumped it will cause a nervy, shock-like sensation. Beyond the elbow, the ulnar nerve travels under muscles inside the forearm and into the hand on the pinkie and ring finger side. The ulnar nerve provides control to the fine motor movements of the hand and flexor muscles of the forearm allowing a strong grip.
Mechanisms of Compression
Prolonged flexion(bending) of the elbow (sleeping with arm flexed) (Triathletes in Aero-bar position)can cause irritation of the ulnar nerve at the elbow. Frequently, the ulnar nerve can slide in and out of the groove in the elbow and irritate/inflame the ulnar nerve. Repeated leaning on the elbow can cause undue pressure on the nerve and excessive pressure on the elbow as in cycling can lead to nerve compression as well. As with athletes and repetitive stress occupations, degenerative arthritis can develop and lead to swelling, cysts and bone spurs at and around the elbow thus compromising the space for nerve transmission. The Flexor Carpi Ulnaris muscle in the forearm can get tight and cause an entrapment of the ulnar nerve. This muscle can get overly stimulated with tennis, racquet sports, poor ergonomics at the desk/computer, excessive phone holding and even activities such as kayaking and crew.
Aching on the inside of the elbow
Numbness and “falling asleep” of the ring and little finger
Difficulty moving fingers and manipulating objects with fingers
Weakening of grip
If chronic, muscle atrophy in palm at ulnar side of hand (pinkie/ring fingers side)
Radiology – MRI may or may not reveal U.T.S. but a worthwhile test to evaluate the nerve, muscle status and any inflammatory changes that may indicate confirmation of this issue. X-Ray will reveal if there is any arthritic changes that may lead to nerve irritation and/or inflammation.
Nerve Conduction studies will most likely be the test of choice to determine if the nerve is working properly and whether the compression is also causing muscle damage.
Applied Kinesiology evaluation is a helpful trouble-shooting tool to assess what muscles are “turned on” or “turned off” due to the nerve entrapment potential. This evaluation will involve muscle testing of the involved extremity, shoulder and neck muscles and structures, as with most of these cases, there are multiple mechanisms of cause and addressing the “upstream” relevant issues may contribute to resolution of this troublesome condition.
A thorough history and intake will frequently uncover mechanisms of this condition so it is important to address lifestyle and work stressors.
As with all nerve related issues, it is important to always look first to the spine and nerve roots for any potential damage or degeneration that may lead to radiculitis/radiculopathy (nerve symptoms along the arm-forearm-wrist-hand-fingers).
Address spinal origin issues with cervical adjustments and/or soft tissue work to “open up” any spinal/disc/nerve irritations
Manual adjustments addressed at correcting shoulder, elbow and wrist/hand joint dysfunctions
Manual soft tissue release techniques to release fascial/muscle restriction over the peripheral nerve fibers in the forearm and shoulder girdle
Electrical trigger point therapy to deeply release myofascial trigger points
Myofascial Dry Needle Therapy addressed at all myofascial blockage points from cervical spine to wrist hand on affected side
Nocturnal bracing for preventing elbow flexion while sleeping
Nerve gliding exercises to facilitate muscle – nerve uncoupling
Short term(30-60 days) nutritional support dosing of proteolytic enzymes (Protrypsin) 3-5 tid, Bioflavonoids (2,000mg/day), Fish Oil (3-6 grams/day), Magnesium (OptiMag 125) 1,000mg/day, Vitamin B6 50 mg bid. This Dr. Michie protocol addresses clinical levels of target nutrients to reduce inflammation, enhance nerve function, release muscle tension and facilitate circulation.
As with all neuro-musculo-skeletal conditions, it is better to clinically address with conservative measures prior to advanced stages. This approach will allow for better and timely outcomes and prevent frustration and unnecessary invasive intervention.