Transcription:
Cubital Tunnel Syndrome

Joey Wahler (Host): You probably don't know the name, but you may know the feeling of a particular type of painful elbow injury, so we're discussing cubital tunnel syndrome.

This is A Bone To Fix, a podcast from the Centers for Advanced Orthopaedics. Hi, I'm Joey Wahler and I've got a bone to fix with you. Thanks for listening. Our guest, Dr. Brian Janz, a hand and upper extremity surgeon with Orthopaedics Associates of Central Maryland Division. Dr. Janz, thanks for joining us.

Brian Janz, MD: Happy to be here.

Joey Wahler (Host): Happy to have you. First, what in a nutshell is cubital tunnel syndrome?

Brian Janz, MD: So cubital tunnel syndrome is a compression of one of the nerves in the upper extremity that causes numbness in the small finger and half of the ring finger and over time will cause weakness of the hand, especially with gripping.

Joey Wahler (Host): And so, it would seem to be somewhat obvious. But for those to whom it's not, what are some of the issues that would bring about?

Brian Janz, MD: So with cubital tunnel syndrome, patients wind up having initially numbness in the small finger and ring finger, which can be annoying. And then over time, it will worsen and have difficulty with sleeping at night, waking up with a hand that you're shaking and kind of numb and achy. And then over time, if that progresses, then it winds up with weakness where you have difficulty with gripping or holding objects. And if it gets really severe, it winds up with muscle wasting where the weakness in the hand will be fairly significant.

Joey Wahler (Host): And so this actually is stemming from the elbow, yes?

Brian Janz, MD: Correct. Yeah. Now, when you have ulnar nerve issues, it usually comes down to one or two areas. One is in the elbow, which is the most common, which is right behind the funny bone. And the second is at the wrist called Guyon's canal. Now, the vast majority of time, if you're going to have numbness in your small finger and it's due to the ulnar nerve, it's going to be most likely at the cubital tunnel or at the funny bone area of your elbow.

Joey Wahler (Host): And that ulnar nerve is actually pretty long in terms of what it connects, right?

Brian Janz, MD: Correct.

Joey Wahler (Host): And so what does it connect? Because I think sometimes until we have an injury, many of us aren't aware of some of the things in different parts of the body that are actually all connected.

Brian Janz, MD: Right. Now, the ulnar nerve comes in on the inside of the arm and runs through the tunnel that causes the problem right behind the funny bone or more technically the medial epicondyle. As that nerve transgresses through the form, it gives innervation to the muscles in the form that help with the gripping and then continues into the wrist where the nerve then progresses into the hand where it'll give sensation to the small finger and ring finger and to the smaller muscles, which help move the fingers.

Joey Wahler (Host): Interesting. So is it possible that if you have cubital tunnel syndrome stemming, as we've said, from the elbow, but affecting these other areas, extremities, is it possible doctor that you have pain in the hand, the fingers, numbness, et cetera, but no pain or numbness in the elbow?

Brian Janz, MD: Correct. You can definitely have symptoms where you're having numbness and weakness in the hand, but you really don't have much going on at the elbow. Now, there's also patients that will have inflammation of the cubital tunnel. So it'll be painful at the elbow and they'll have the same symptoms at the hand. So you can have it either way, but the issue is usually at the elbow though.

Joey Wahler (Host): Gotcha. And so before we go any further, what typically causes this condition?

Brian Janz, MD: This is a sporadic condition. There's really no known causes. But if you wind up having trauma to the area or repetitive activities of movement involving the elbow where the nerve is being stretched or direct compression, so say you're sitting at a chair, working at a desk eight hours a day, and you're constantly compressing that funny bone area, then that can lead to irritation or inflammation that can cause the cubital tunnel syndrome.

Joey Wahler (Host): So when you say compressing, you mean kind of the manner in which a lot of people might hold their arm and position their elbow, right?

Brian Janz, MD: Correct.

Joey Wahler (Host): So, what should you try to avoid there to keep away from this happening as much as possible on your own?

Brian Janz, MD: So if you are developing symptoms, some of the home remedies that you can use are avoiding activities in which you're bending your arm for a long period of time. Also, if you're using a computer, make sure that your chair is not too low or you're not resting your elbow on that armrest. You can also avoid leaning on your elbow or putting pressure directly on that area where the nerve runs right behind the funny bone.

Joey Wahler (Host): How does cubital tunnel syndrome differ from tennis elbow?

Brian Janz, MD: So tennis elbow is going to be an inflammation of the epicondyle. So the nerve actually isn't involved, it's more of a tendon inserting under the bone and that is torn off a little bit. And that's going to be more aching pain, especially with extension and flexion of the wrist or gripping, but your pain and discomfort's going to be fairly specific at the elbow and radiating up and down. Cubital tunnel syndrome is going to be more of an irritation, inflammation, or compression of the nerve in which you're going to have that numbness, tingling and weakness of the hand, plus or minus the discomfort at the inside of the elbow.

Joey Wahler (Host): Now, I had several years ago tennis elbow myself. And I'm wondering if something that applies with that applies to cubital tunnel syndrome. Namely, we were talking a moment ago about trying to protect yourself against this, and I know one way from experience now, unfortunately, is when you're working out, let's say lifting weights. You want to try as much as possible to keep from locking your elbows, because that is a great way or, not so great way as it were, to put that additional burden on the elbow, right?

Brian Janz, MD: Correct. Now, a tennis elbow, that's usually tendonitis you're going to see in the outside of the elbow, which is going to be more on the thumb side. The golfers' elbow or medial elbow epicondylitis, you'll see more on the inside of the elbow. And it's more pain and discomfort kind of on the bump, also called your medial epicondyle. And those are very specific pains to those areas and the ulnar nerve which runs behind the medial epicondyle can be inflamed or achy in that area. But it usually is a different type of pain, more of a nerve type of pain, as opposed to an aching and pain that you're going to have with gripping.

Joey Wahler (Host): Understood. So getting back to cubital tunnel syndrome and the gripping issues, et cetera. If you see those symptoms in a patient, how do you test, how do you diagnose to be sure that it's actually coming from that condition?

Brian Janz, MD: So one of the initial and best tests is a clinical examination. Being able to look at the arm, figure out what's aching, what is numb, what's tingly will pinpoint whether or not we're looking at carpal tunnel syndrome, cubital tunnel syndrome, or mixture of both and whether or not there's pain and discomfort inflammation at the cubital tunnel behind the medial epicondyle or weakness in the certain muscles of the hand will help us also pinpoint the diagnosis.

Now, if we have a feeling that there is cubital tunnel syndrome, then we'll probably wind up getting an x-ray to take a look at the elbow to make sure we don't have any arthritic processes or spiny processes in the area of the nerve that could be causing a compression more from a structural standpoint.

Most of the time the x-rays are going to be normal. Next step then is going to proceed with a EMG or nerve conduction study in which a physician will start from the neck and test all the way down for the major nerves in the arm and upper extremity. And we'll be able to tell whether or not there's a compression of the nerve coming across the cubital tunnel, and that's fairly diagnostic and we can get a measurement of either mild, moderate, or severe compressions by that test, which can kind of help us with treatment modalities.

Joey Wahler (Host): And speaking of those treatment modalities, what would those be?

Brian Janz, MD: A lot of times with cubital tunnel syndrome, as long as it's mild, you can treat that in a nonsurgical manner. And we usually start out with anti-inflammatories such as NSAIDs. We can also use nighttime splinting, which is important. When we wind up going into deep sleep at night, we wind up flexing our elbows and that puts a little pressure onto the ulnar nerve that crosses that area, where it goes through the tunnel. So by keeping the arms straight, it helps decrease some of the inflammation that you would otherwise have with the nerve at night. And for mild or moderate cubital tunnel syndrome, that works pretty well. And then if anti-inflammatories aren't working or the numbness is fairly persistent, or if it's more moderate and severe with regard to the compression, then the best treatment would be surgical release to take the pressure off the nerve.

Other than endoscopic or in situ releases, we also have the submuscular transposition or the anterior transposition of the ulnar nerve. And in those situations, we're moving the nerve onto the other side of the epicondyle, so that way it's not stretching or popping over the epicondyle. And those are a little bit more invasive procedures and usually take a little bit more recovery time in order to get back to normal.

Joey Wahler (Host): And if surgery is in fact needed, what does that do actually?

Brian Janz, MD: So once we decide on surgical treatment options, there's a couple different options available to release the nerve at the cubital tunnel. A smaller incision would be the endoscopic release where an incision's made several centimeters and with an endoscope, very similar to carpal tunnel, will go in there with an endoscope and a blade and safely release the cubital tunnel endoscopically. Another option is to make a smaller incision and release the cubital tunnel, but leave it in its same position, called an in situ release.

Joey Wahler (Host): And then finally, doctor, baseball fans, I don't know if you're one, doc, but those like myself are familiar with the term ulnar nerve or the name ulnar nerve, because it's associated with Tommy John's surgery for pitchers that hurt that particular part of the body. But we're not talking about that here, right?

Brian Janz, MD: No. Now, with Tommy John surgery and with injuries when pitching, that's related to your ulnar collateral ligament, which is in the same area, but that's more of a structural issue with stability of the elbow. Now, you can also have cubital tunnel syndrome and nerve issues with injuries to the ulnar collateral ligament, so sometimes those are dealt with or treated hand in hand.

Joey Wahler (Host): So, ulnar can mean different things for different people is the bottomline, right?

Brian Janz, MD: Yes.

Joey Wahler (Host): Well, folks, we trust you're now more familiar with cubital tunnel syndrome. Dr. Brian Janz, thanks so much again.

Brian Janz, MD: Thank you for having me.

Joey Wahler (Host): And for more information or to make an appointment, please do visit mdbonedocs.com. Again, that's M-D-B-O-N-E-D-O-C-S.com. And that was a bone that's fixed. If you found this podcast helpful, please share it on your social media. Hoping your health is good health, I'm Joey Wahler.