Description
Ulnar nerve entrapment occurs when one of the nerves in the arm (the ulnar nerve) becomes compressed and can’t function normally. This can give symptoms of “falling asleep” in the ring finger and little finger, especially when the elbow is bent. You may have aching pain on the inside of the elbow.

In some cases, you may have trouble moving the fingers in and out, or manipulating objects. Carpal tunnel syndrome has similar symptoms but involves a different nerve (the median nerve). Carpal tunnel syndrome typically causes tingling in the thumb, index finger and long finger.

The ulnar nerve is one of the three main nerves in the arm. It travels from under the collarbone and along the inside of the upper arm. It passes through a tunnel (the cubital tunnel) behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly called the “funny bone.”

Beyond the elbow, the nerve travels under muscles on the inside of the arm, and into the hand on the pinky side of the palm. When the nerve goes into the hand, it travels through another tunnel (Guyon’s canal). The most common place where the nerve gets compressed is behind the elbow. Sometimes it gets compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck.

The nerve functions to give sensation to the little finger and the half of the ring finger that is near the little finger. It also controls most of the little muscles in the hand that help with fine movements, and some of the bigger muscles in the forearm that help to make a strong grip.

Risk Factors/Prevention
It is not known exactly what causes compression of the ulnar nerve. Some factors can make it more likely that the nerve will be compressed. These include prior fractures of the elbow, bone spurs, swelling of the elbow joint, or cysts. A direct blow to the inside of the elbow, leaning on the elbow for prolonged periods, or repetitive activity that requires a bent elbow can irritate the nerve if it is already compressed. If the ulnar nerve is compressed at the wrist, the cause is more likely to be a cyst in Guyon’s canal.

Symptoms
Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment. Often these symptoms come and go. They happen more often when the elbow is bent, such as when you are driving or talking on the phone. Some people wake up at night because their fingers are numb. You may also have weakness of grip and difficulty with finger coordination (such as typing or playing an instrument). If the nerve is very compressed or has been compressed for a long time, muscle wasting in the hand can occur. Once this happens, muscle wasting cannot be reversed. For this reason, it is important to see the doctor as soon as you experience any of the symptoms.

Diagnosis
Always see an orthopaedist if you are having symptoms of ulnar nerve entrapment that interfere with normal activities or last more than a few weeks.
The doctor will examine the arm to check the nerve, and try to determine where the nerve is compressed. If the nerve is irritated, tapping over the nerve at the “funny bone” can cause a shock into the little finger and ring finger, although this can happen when the nerve is normal as well. The doctor will probably move the shoulder, elbow and wrist to see if any of these cause symptoms. The doctor will test the sensation in the fingers.

Although most causes of compression of the ulnar nerve cannot be seen on X-ray, the doctor may take an X-ray of the elbow or wrist to look for bone spurs, arthritis or other places that the bone may be compressing the nerve. If the doctor thinks that the nerve is compressed at the wrist, a CT scan (computed tomography) or MRI (magnetic resonance image) may be recommended to see if a cyst or other structure is the cause of the compression.

The doctor may recommend nerve conduction studies. These are special tests to determine how well the nerve is working and to help localize the area of compression. Nerves work like wires; when the nerve is not working well, it takes too long for the nerve to conduct. During this test, the nerve is stimulated in one place; the amount of time it takes for the response to be conducted to another place is determined. The area where the nerve conduction takes too long is likely to be the place where the nerve is compressed. Sometimes, a small needle is put into some of the muscles that the ulnar nerve controls. This can determine if there is any evidence of muscle wasting.

Treatment Options
Unless you have a lot of muscle wasting, your doctor will probably recommend nonsurgical treatment initially. The following treatments may help to improve the symptoms. They may be all the treatment you need.

• Avoid frequent use of the arm with the elbow bent. If you use a computer frequently, make sure that your chair is not too low. Do not rest the elbow on the armrest.
• Avoid leaning on the elbow or putting pressure on the inside of the arm. For example, do not drive with the arm resting on the open window.
• Keep the elbow straight at night when you are sleeping. This can be done by wrapping a towel around the straight elbow, wearing an elbow pad backwards, or using a special brace.

If symptoms are acute, the doctor may recommend that you take an anti-inflammatory medicine such as ibuprofen to help reduce swelling around the nerve. Steroid (cortisone) injections around the ulnar nerve are not generally used because there is a risk of damage to the nerve.

Some doctors think that exercises to help the nerve slide through the tunnels can improve the symptoms. These exercises can help keep the arm and wrist from getting stiff.

Treatment Options: Surgical
If you are not improving with the strategies listed above, if the nerve is very compressed, or if you have muscle wasting, the doctor may recommend surgery to take pressure off of the nerve. Most often, the surgery is done around the elbow, but it can be done at the wrist if that is the place of the compression. Sometimes, the nerve is compressed in both places, so surgery is done at both the elbow and the wrist.

Surgeons use various ways to relieve compression from the nerve around the elbow. All of the operations involve making an incision around the elbow. In one operation, only the “roof” is taken off of the cubital tunnel. This tends to work best when the nerve compression is mild. More commonly, the nerve is moved from its place behind the elbow to a new place in front of the elbow. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). There are many factors that go into deciding where the nerve is moved. The doctor will recommend the best option for you.

If the nerve is compressed at the wrist, a zigzag incision will be made at the base of the palm on the pinky side. The surgeon will open the roof of Guyon’s canal to take the pressure off the ulnar nerve. If there is a cyst or another reason for the compression, the surgeon will remove that at the same time.
The surgery is usually done on an outpatient basis or with an overnight stay in the hospital. Depending on the type of surgery, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (3-6 weeks) in a splint. The surgeon may recommend physical therapy to help you regain strength and motion in the arm.

The results of the surgery are generally good. If the nerve is very badly compressed or if you have muscle wasting, the nerve may not be able to get back to normal and you may have some symptoms even after the surgery. Nerves recover slowly, and it can take a long time to know how well the nerve will do after the operation.

Description
Tennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside (lateral side) of the elbow. The tendons involved are responsible for anchoring the muscles that extend or lift the wrist and hand (see Figure 1).

Risk Factors/Prevention
Tennis elbow happens mostly in patients between the ages of 30 years to 50 years. It can occur in any age group. Tennis elbow can affect as many as half of athletes in racquet sports. However, most patients with tennis elbow are not active in racquet sports. Most of the time, there is not a specific traumatic injury before symptoms start. Many individuals with tennis elbow are involved in work or recreational activities that require repetitive and vigorous use of the forearm muscles (see Table 1). Some patients develop tennis elbow without any specific recognizable activity leading to symptoms.

Symptoms
Patients often complain of severe, burning pain on the outside part of the elbow. In most cases, the pain starts in a mild and slow fashion. It gradually worsens over weeks or months. The pain can be made worse by pressing on the outside part of the elbow or by gripping or lifting objects. Lifting even very light objects (such as a small book or a cup of coffee) can lead to significant discomfort. In more severe cases, pain can occur with simple motion of the elbow joint. Pain can radiate to the forearm.
To diagnose tennis elbow, tell the doctor your complete medical history. He or she will perform a physical examination.

• The doctor may press directly on the bony prominence on the outside part of the elbow to see if it causes pain.
• The doctor may also ask you to lift the wrist or fingers against pressure to see if that causes pain.

X-rays are not necessary. Rarely, MRI (magnetic resonance imaging) scans may be used to show changes in the tendon at the site of attachment onto the bone.

Treatment Options
In most cases, nonoperative treatment should be tried before surgery. Pain relief is the main goal in the first phase of treatment. The doctor may tell you to stop any activities that cause symptoms. You may need to apply ice to the outside part of the elbow. You may need to take acetaminophen or an anti-inflammatory medication for pain relief.
Orthotics can help diminish symptoms of tennis elbow. The doctor may want you to use counterforce braces and wrist splints. These can reduce symptoms by resting the muscles and tendons (see Figure 2).

Symptoms should improve significantly within four weeks to six weeks. If not, the next step is a corticosteroid injection around the outside of the elbow. This can be very helpful in reducing pain. Corticosteroids are relatively safe medications. Most of their side effects (i.e., further degeneration of the tendon and wasting of the fatty tissue below the skin) occur after multiple injections. Avoid repeated injections (more than two or three in a specific site).

After pain is relieved, the next phase of treatment starts. Modifying activities can help make sure that symptoms do not come back. The doctor may want you to do physical therapy. This may include stretching and range of motion exercises and gradual strengthening of the affected muscles and tendons (see Figure 3). Physical therapy can help complete recovery and give you back a painless and normally functioning elbow. Nonoperative treatment is successful in approximately 85 percent to 90 percent of patients with tennis elbow.

Treatment Options: Surgical
Surgery is considered only in patients who have incapacitating pain that does not get better after at least six months of nonoperative treatment.
The surgical procedure involves removing diseased tendon tissue and reattaching normal tendon tissue to bone (see Figure 4). The procedure is an outpatient surgery; you do not need to stay in the hospital overnight. It can be performed under regional or general anesthesia.

Technique for surgical treatment of lateral epicondylitis. A, Skin incision over the lateral epicondyle. B, Distal reflection of the extensor mechanism exposing the lateral compartment of the elbow. C, Excision of pathologic tissue from the underside of the extensor mechanism. D, Decortication of the lateral epicondyle. E, Drilling of two V-shaped tunnels within the lateral epicondyle. F, Reattachment of the extensor mechanism to the lateral epicondyle. G, Side-to-side repair of the extensor tendon mechanism.

Most commonly, the surgery is performed through a small incision over the bony prominence on the outside of the elbow. Recently, an arthroscopic surgery method has been developed.

So far, no significant benefits have been found to using the arthroscopic method over the more traditional open incision.

After surgery, the elbow is placed in a small brace and the patient is sent home. About one week later, the sutures and splint are removed. Then exercises are started to stretch the elbow and restore range of motion. Light, gradual strengthening exercises are started two months after surgery. The doctor will tell you when you can return to athletic activity. This is usually approximately four months to six months after surgery. Tennis elbow surgery is considered successful in approximately 90 percent of patients.