Cubital Tunnel: Secrets Of A Hand Therapist

Understanding the Cubital Tunnel

What is it?

Cubital tunnel is commonly known as the ‘funny bone’ and is the inside of the elbow that houses the ulnar nerve. When the ulnar nerve gets irritated at this location, it is referred to as ‘Cubital tunnel Syndrome’.

Nerves that go to your hand function like a garden hose. They leave your neck, cross your shoulder, travel down your arm and split into three different nerved to go out to your hand. Specifically, your ulnar nerve leaves your neck (at the level of the C8-T1 vertebraes), travels through your shoulder, around your elbow on the inner portion (your funny bone) down the inside and front side of your forearm and into your small finger and ring finger. It innervates the small finger and ring finger, conducting the sensation to these fingers and then takes a sharp turn to feed the internal small motor muscles of your hand and thumb. This is the nerve that we are most concerned with.

Just like a hose, if anywhere along the nerve gets compressed or ‘kinked’ from inflammation or through a mechanical compression, the end result will be the same. Just like a full kink in a hose with no water getting through, if your nerve is not being allowed to get any conduction through it, your symptoms will be numbness. If you are getting some conduction through but not the optimal amount, it will be feel like tingling in your small finger and ring finger. If you have just a tiny bit of irritation on the nerve, it will feel heavy, achy, and/or fatigued, along with pain. All of these symptoms are the nerve’s way of speaking to you. It is telling you to address it.

Typical Symptoms

Usually the first complaints I hear are a heavy feeling in the arm or general aches along the forearm, cramping in the forearm flexors, fine motor loss, or numbness or tingling traveling into the small finger or ring finger. This is usually described as a feeling of ant’s crawling on the fingers or a ‘buzzing’ in them that can not be explained. If the ulnar nerve is compressed or irritated long enough, this can lead to permanent muscle loss and sensation deficits. Functionally, this usually equates to the inability to write, use tools, or sustain positions for periods of time (as in sleeping), obviously leading to a decreased quality of life and increased pain.

Treatment

As a certified hand therapist, we can focus on decreasing the inflammation by finding the root causes of the irritation and helping to educate patients on how to reduce their symptoms resulting in a recovery of the nerve. Of course, there are certain situations that the nerve has been compressed and irritated for so long or so badly that this is not possible. In this situation, a Hand surgeon consultation would be the next avenue to explore. They can either do surgery to ‘decompress’ or remove the tight overlying tissue that is squeezing the nerve, or actually move the nerve to a different location to allow a little more slack on it allowing recovery to most easily happen by preventing all irritating posture that can irritated the nerve. A qualified hand surgeon will be able to diagnose and determine the appropriate intervention if you get to this stage.

Of course, there are some diagnosis that can mimic ulnar nerve symptoms too that you’ll want an MD to rule out before you treat cubital tunnel as such. These can include, but are not limited to a lung tumor (Pancoast Tumor), problems originating at the neck or shoulder, and or at the wrist along with other things.

* This information is to be used for educational purposes only. It is not my intention to treat or diagnosis patient’s with this module and patients should seek advice from their medical professionals for a diagnosis and treatment if they are intending on treating symptoms.

Treatment of the nerve

Exercises that will help to reduce your symptoms

#1 Forearm flexor stretches.

Gently bring the palms together and press down towards the belly button to allow a stretch in the forearm flexors. Hold this stretch for 30 seconds and repeat this 3- 6 times a day just to the point of tension but not to the point of discomfort. If there is an increase of pain, typically it is because the patient is pushing this stretch too hard. If any numbness, tingling or shooting pain occurs, they should stop.

An Alternative to this stretch if this is uncomfortable, is to stretch the flexors with the elbows at the side. Bend the wrist with the uninvolved hand while keeping the elbow at 90 degrees to the end of the comfortable range and hold it here 30 seconds twice through 3 times per day. It is important to stretch to the point of tension but not to the point of discomfort as this will cause an inflammatory response that we are trying to avoid. If there is an increase of pain, typically it is because someone is pushing this stretch too hard and they need to ease off the stretch. Try to avoid this.

In the clinic, I use a product called a power web that helps to assist the stretch and many people like the way that it feels. I have included it in a link in case you would like to explore that option.

Once you can complete this without pain for 3 days, and not before then, progress to straightening your elbow to intensify the stretch. Complete the same exercise without the bend in your elbow. This will lengthening the tendon even more.

* It is important not to progress this exercise too soon and before you can complete it without any discomfort at all or you will cause an increase of inflammation in your tendon thus delaying your recovery.

#2 Ulnar nerve glides

Starting with your affected arm with elbow in flexion and wrist reaching towards your shoulder, extend your elbow out followed by your wrist and slowly flex your elbow and extend your wrist back as if you are holding a tray of food. Stop where you begin to feel even the slightest tension or pull in your arms. Return to the starting position and repeat 5-10 times. Don’t hold this position for any length of time as the goal of this exercise is to move the nerve without stretching it. If any numbness, tingling or pain occurs, stop.

#3 Brachial plexus nerve glide

Pretend you have a bird in your palm at the center of your chest and slowly release the bird out to the side. Again, go to where you begin to feel even the slightest tension or pull in your arms. Return to the starting position and repeat 5-10 times. Don’t hold this position for any length of time as the goal of this exercise is to move the nerve without stretching it. If any numbness, tingling or pain occurs, stop.

#4 Foam Roller Thoracic mobilization

As long as you do not have a history of back or neck problems, car accidents or pain in either, you can try mobilizing the mid-back.

Increased curvature of the mid-back is often linked to sedentary that involve a lot of screen watching and sitting because of the postures and gravity’s demands. Forward rounding for a prolonged period of time can lead to compensatory curving of the spine. Increased curvature of the spine can lead to headaches, tightness, pain, numbness or tingling in the arms/hands. Foam rolling is a great way to passively improve mid-back mobility and allow for relief of some of these symptoms.

Start by lying perpendicular to the foam roller with the roller in the mid back just below the level of your shoulder blades and lean into it only so much to where there is no pain or discomfort. Roll the foam roller up your back using some of your body weight to allow a deep but gentle ‘massage’ to the spine. This should only feel good and if there is any pain or increased symptoms, you should stop. Repeat up to 10 times once a day.

#5 Foam Roller Pectoralis Minor Stretching

As long as you do not have a history of back or neck problems, car accidents or pain in either, you can try stretching your pectoralis minor on a foam roller.

We live in a world that everything that we do is in front of us. Our arms are interacting with our daily life in a forward reaching position. We drive forward, we type forward, we eat forward, we text forward, we read forward. This leads to our shoulders always being in a forward hunched position. Over time, this leads to very weak muscles in your upper back, and a shortened pectoralis minor muscle in across your chest. The muscle starts to get tight across your chest and it is harder and harder to stay in an upright position with our shoulders back and down the way they are anatomically designed to do. One way we stretch the pectoralis minor is with a foam roller.

Lie on top of the foam roller face towards the ceiling, your knees bent to protect your lower back, feet shoulder width apart, and chin tucked in a comfortable position. With your hands down to the side resting on the ground, palm up, slowly and gently take a few breathes. Some people already feel a stretch in their chest just by getting into this position. If you are one of these people, I would recommend you stay in this position for 3-5 minutes allowing the pectoralis minor muscle to stretch. If you do not feel as stretch just by being in this position, try moving your hands towards your head while leaving them on the ground that you are working on as if making ‘snow angels’ as you did when you were a child. You should stop if there is any numbness, tingling, or pain as this is a sign that the nerve is not in a position that is ready to be challenged. Repeat 10 times slowly once a day.

I like a medium firmness roller that is inexpensive:

Night time positioning’s contribution to your symptoms

The number one cause that I see in the clinic of cubical tunnel syndrome is a flexed elbow at night. As mentioned previously, the ideal position for your ulnar nerve to recover in is extension of the elbow. This doesn’t mean that your elbow needs to be ‘Frankenstein straight’. It just means that it needs to not be flexed past 30° for the 6 to 10 hours that you are asleep. As you cannot be held responsible for what you do while you are unconscious, I typically tell people to wrap their elbows with either a pillow or a towel and gently and lightly secure it with some sort of light tape so that it is a mechanical block for their elbows to flex. I have them make it to where they can slide it on or off so that to ensure that it is not too tight on the elbow and so that they only need to make it once ensure good compliance and follow through and to minimize that elbow flexed that arm.

A splint or brace while sleeping can be used to keep the elbow from bending while you are asleep if the towel wrap is not effective. The brace I prefer is listed below.

How to fabricate a soft elbow extension splint:

Step 1 - Fold a large beach towel or use a pillow to block the crease at the elbow

Step 2 - Wrap the towel or pillow around the elbow, like a "pig in a blanket", and hold in place with duct tape. The sleeve should be loose enough to slide in and out of without difficulty. Care should be taken to not squeeze the arm.

Avoid any compression around the ulnar nerve such as an ace bandage or a tight covering or sleeve as this can result in further compression and damage to the nerve.

If a patient is a side sleeper, I encourage them to make sure that their shoulder is not being either compressed by laying on the affected side or that the nerve is not being stretched by allowing the arm and hand to arm to fall over across their body. This is achieved by placing pillows either under the head and one under the ribs if they are laying on their affected shoulder or building your pillows up so high that when they are resting their hand, it is above where their shoulder would be.

There are products out there that help position your elbow for you if you can not or a towel is not comfortable to sleep in. What I typically recommend to patient's are the following to sleep in:

My favorite is the Pil-O splint:

Or as an alternative if patient's need or want an alternative daytime option, I will recommend this:

Other activities that can be aggravating to the ulnar nerve and that should be avoided.

1. Repetitive elbow flexion and extension (i.e., hammering)

2. Sustained elbow flexion (i.e., holding a phone to ear/texting, sleeping position)

3. Traction on the arm (i.e., pulling a cart)

4. Direct pressure on the nerve (i.e., resting elbow/forearm on a hard surface)

5. Resting hands on top of head

6. Any other activity that increases numbness or tingling in the last 2 fingers of the hand.

These activities should be minimized

Posture’s contribution to your symptoms

In review of the course of this nerve, nerves function like a garden hose. The Ulna Nerve leaves your neck (C8-T1 vertebrae), travels through your shoulder, around your elbow on the inner portion (your funny bone) down the inside and front side of your forearm and into your small finger and ring finger. It innervates the small finger and ring finger, feeding the sensation and then hooks around feeding the internal small motor muscles of your hand and thumb. This is the nerve that we are most concerned with.

In the majority of the cases that I see, compression along the ulnar nerve happens as it goes around the cubital tunnel otherwise known as the ‘funny bone’. This is the true definition of cubital tunnel syndrome, but it may not be the only contributing factor to the irritation of the nerve. Just as if you were to kink a hose in multiple places along the length of a hose, the water would not flow well out the end, the same thing can happen with your nerves.

The compression can be happening right at the Spicket (the neck), through the Brachial Plexus, or as it crosses your wrist into your hand at the Guyon’s Canal. The most common compression or ‘kink’ that I see when someone develops Cubital Tunnel, is some sort of irritation along the rest of the nerve – often times at the upper back and into the neck usually caused by looking down onto electronice. This is good news for you because typically it is an easy fix and knowing this, you can help your posture improve to allow the nerve to conduct optimally.

We live in a world that everything that we do is in front of us. Our arms are interacting with our daily life in a reaching position. We drive in a forward position, we type on our keyboards forward, we eat forward, we text forward, we read forward. This leads to our shoulders always being in a forward hunched position. From the time we are in junior high, especially large chested women, we learned to walk around with poor posture in fear that our peers will think that we are posturing for more status or have boastful confidence. Over time, this leads to very weak muscles in your upper back, and a shortened pectoralis minor muscle in across your chest. The muscle starts to get tight across your chest and it is harder and harder to stay in an upright position with our shoulders back and down the way they are anatomically designed to do.

The simplest way to fix your posture is to practice having good posture breaks multiple times throughout the day. I tell my patients that at least three times a day, set a timer to go off where in which they will pay attention to where they are in space. I instruct them to roll their shoulders backwards ten times and breathe to bring awareness to where their holding their bodies and begin to position them in a more anatomically appropriate position. Imagine pulling a string from the top of your head to the ceiling. Most of the time, this alone is helpful for positioning but occasionally I do a few more exercises to help encourage muscle balance. I go over these in the exercise chapter of this blog.

Ergonomics’ contribution to ulnar nerve symptoms

For ulnar nerve irritation, a large contributing factor for recovery of the nerve is typically keeping your elbow extended for long periods of time. As your elbow is flexed beyond 30°, the ulnar nerve starts to have stress. This means that 90°, the position that we typically type or mouse in, can be an aggravating position in and of itself. This doesn’t mean that we can’t perform our work, it just means that we need to take breaks from being in a flexed positions for long periods of time and periodically stretch our elbows out straight. It also means that we should be careful not to flex our elbows past 90°, as in the case of a workstation that is set to high. In any case, time spent in any variation of flexion beyond even 30 degrees can lead to irritation even with a properly set workstation.

Another thing that I have found will irritate the ulnar nerve is if someone rests their body weight on top of the cubital tunnel as they try to perform tasks. This means that using armrests while at work for eight hours, or resting your elbow on the center console of the car while you try to drive can be aggravating as well. I typically suggest to my patient to either push their armrests down to the point in which they can not use them or take them off completely until they recover or sometimes indefinitely if they are prone to developing the irritation. In the car, just avoiding placement of the elbows on the center console while driving typically helps.

The other thing that is worth mentioning is the position of the hand while trying to mouse. If the ulnar nerve is irritated even at the cubital tunnel, typically anywhere closer to the finger tips than the elbow along the same nerve path will be prone to irritation. This means that by resting on your ulnar nerve at the Guyon’s canal while we are mousing can only aggravate things. The Guyon’s canal is the area at the base of where the hand bone attaching to the pinky and wrist meet. I instruct my patients to hoover over the surface that they are mousing on instead of resting their wrist at the same time as using their mouse. If they cannot for whatever reason, a pad at the wrist level can be helpful, but not as ideal as hoovering.

Thermal Modalities

Thermal modalities are heating and cooling techniques used to bring relief the symptoms of ulnar nerve irritation to bring increased mobility/dexterity and decrease pain.

For the first two weeks after an irritation occurs, I typically tell my patients to ice three times a day for 10 minutes. Make sure to have a piece of material between the ice and the skin so that to ensure that the area does not become too cold as it does not ‘feel’ as well as well innervated skin. I usually tell patient’s that a warm shower in the morning is typically enough heat to allow for a good conduction of the ulnar nerve optimal.

Most people with nerve irritation cringe at the thought of using cold on their hands because warmth usually make the hands feel better and less stiff, but cold can help when things are inflamed and swelling. The good news is that people should only use cold 1) when it works and they respond well to it and 2) should only be done to tolerance (not longer than 10 minutes of a upper extremity).

If someone is really adverse to ice, they can use the following:

Crushed peas or corn because these frozen bags can contour to small areas better

Cool water

Raw rice left in a freezer (this won’t have the water content that ice doesn’t so it won’t get as cold)

Heat is used to improve mobility only when the elbow is stiff, but no inflammation or warmth/redness is present. It can be used to help alleviate pain. The following heating methods are popular:

Warm water (can be a bath or shower)

Paraffin Units (can be purchased commercially)

Towels dipped in very warm water and covered with another dry towel

I don't typically formally recommend paraffin units, but patient's often ask me about them so I have included an inexpensive version here. There is no need to get a really expensive unit.

Conclusion

In the end, symptoms should start to improve over the course of 6 weeks and will continue to improve for 3 months. If at any time, symptoms worsen or fail to make improvement despite diligent performance of exercise and compliance with positioning, I always encourage patients to return to their MD for further evaluation, imaging, or diagnostic testing like a nerve conduction study.

Hand Fix Rehab

Anytime for busy people