Cubital and radial tunnel syndrome

Tunnel neuropathies account for 1/3 of diseases of the peripheral nervous system. More than 30 forms of tunnel neuropathies have been described in the literature [Levin O.S., 2005]. Various forms of compression-ischemic neuropathies have their own characteristics. We will first consider their general characteristics, then we will focus on the most common forms of hand tunnel syndromes (Table 1).

Causes

The anatomical narrowness of the canal is only a predisposing factor in the development of tunnel syndrome. In recent years, evidence has accumulated indicating that this anatomical feature is genetically determined. Another reason that can lead to the development of tunnel syndrome is the presence of congenital developmental anomalies in the form of additional fibrous cords, muscles and tendons, and rudimentary bone spurs. However, predisposing factors alone for the development of this disease are usually not enough. Some metabolic and endocrine diseases (diabetes mellitus, acromegaly, hypothyroidism), diseases accompanied by changes in joints, bone tissue and tendons (rheumatoid arthritis, rheumatism, gout), conditions accompanied by hormonal changes (pregnancy), space-occupying formations can contribute to the development of tunnel syndrome the nerve itself (schwannoma, neuroma) and outside the nerve (hemangioma, lipoma). The development of tunnel syndromes is facilitated by frequently repeated stereotypical movements and injuries. Therefore, the prevalence of carpal tunnel syndrome is significantly higher in people engaged in certain activities and in representatives of certain professions (for example, stenographers have carpal tunnel syndrome 3 times more often).

Carpal tunnel syndrome

The term “Tunnel syndrome” includes a fairly large group of diseases of peripheral nerves caused by their pinching or compression in natural channels - tunnels. What channels are there in the bones, muscles and tendons of our body. Currently, several dozen tunnel syndromes have been studied. Some are very common, while others are extremely rare. At the same time, the reason for the development of all types of tunnel syndromes is the same - pathological capture and a kind of compression of the nerve in its natural canal.

In this article you will get answers to the following questions:

• What is carpal tunnel syndrome?
• Types of tunnel syndromes.
• Tunnel syndromes - causes.
• Symptoms of tunnel syndromes.
• Diagnosis of tunnel syndromes.
• Carpal tunnel syndrome - how to treat?

Clinical manifestations

The full picture of tunnel syndrome includes sensory (pain, paresthesia, numbness), motor (decreased function, weakness, atrophy) and trophic disorders.
Various clinical course options are possible. Most often it starts with pain or other sensory disorders. Less commonly, it begins with movement disorders. Trophic changes are usually expressed insignificantly and only in advanced cases. The most characteristic feature of carpal tunnel syndrome is pain. Typically, pain appears during movement (load), then occurs at rest. Sometimes the pain wakes the patient up at night, which exhausts the patient and forces him to see a doctor. Pain in tunnel syndromes can include both a nociceptive component (pain caused by inflammatory changes occurring in the area of ​​the nerve-canal conflict) and a neuropathic component (due to nerve damage). Tunnel syndromes are characterized by manifestations of neuropathic pain such as allodynia and hyperpathy, a sensation of electric current passing (electrical shooting), and burning pain. In later stages, pain may be due to muscle spasms. Therefore, when choosing pain therapy, it is necessary to be guided by the results of a thorough clinical analysis of the characteristics of the pain syndrome. Motor disorders arise as a result of damage to the motor branches of the nerve and manifest themselves in the form of decreased strength and rapid fatigue. In some cases, the progression of the disease leads to atrophy and the development of contractures (“clawed paw”, “monkey paw”).

With compression of arteries and veins, vascular disorders may develop, which is manifested by pallor, a decrease in local temperature, or the appearance of cyanosis and swelling in the affected area. With isolated nerve damage (in the absence of compression of arteries and veins), trophic changes are most often insignificantly expressed.

Diagnostics

As a rule, the diagnosis is established on the basis of the characteristic clinical manifestations described above. It is convenient for the clinician to use a number of clinical tests that allow differentiating different types of carpal tunnel syndromes. In some cases, it is necessary to conduct electroneuromyography (the speed of impulses along the nerve) to clarify the level of nerve damage. Nerve damage, space-occupying lesions or other pathological changes causing carpal tunnel syndrome can also be determined using ultrasound, thermal imaging, MRI [Horch RE et al., 1997].

Kinds

There are more than 30 types of carpal tunnel syndrome, among the main and most common ones we should highlight:

• carpal tunnel syndrome;
• cubital tunnel syndrome;
• elbow;
• peroneal tunnel syndrome;
• tarsal.

Most often, patients experience carpal tunnel syndrome (1.5% of the world's population). The arms suffer more from neuropathy than the lower extremities. Even less often, doctors are consulted with tunnel neuropathy of the trunk.

Stop exposure to the pathogenic factor. Immobilization

The first thing to do is to stop physical impact on the affected area. Therefore, immobilization in the affected area is necessary. Recently, special devices have appeared in our country - orthoses, bandages, splints, which allow immobilization in the area of ​​injury. At the same time, they are very convenient to use, they can be put on and taken off very easily, which allows the patient to maintain his social activity (Fig. 1). These funds are widely and successfully used abroad. Studies have appeared on the effectiveness of splinting, which have convincingly shown that it is quite comparable to the effectiveness of hormone injections and surgical operations. In our country, these devices are already used by traumatologists; They are clearly not yet sufficiently introduced into neurological practice.

Cubital tunnel syndrome: symptoms and diagnosis

A third of peripheral nervous system diseases are tunnel neuropathies. Tunnel syndrome is usually defined as a complex of clinical manifestations (sensitive, motor and trophic) caused by compression, pinching of a nerve in narrow anatomical spaces (anatomical tunnel). But under certain pathological conditions, the channel narrows, and a nerve-channel conflict arises [Al-Zamil M.Kh., 2008].

Cubital tunnel syndrome

Cubital tunnel syndrome (Sulcus Ulnaris Syndrome) is the result of compression of the ulnar nerve in the cubital tunnel in the area of ​​the elbow joint between the internal epicondyle of the humerus and the ulna. The second most common condition after carpal tunnel syndrome.

Causes. Cubital tunnel syndrome can be caused by frequently repeated flexion of the elbow joint, i.e. This is overuse syndrome. Cubital tunnel syndrome can develop with normal, frequently repetitive movements (most often associated with a specific occupational activity) in the absence of obvious traumatic injury and as a result of direct trauma (for example, when leaning on the elbow while sitting). Patients with diabetes and alcoholism are at greater risk of developing cubital tunnel syndrome.

Clinical manifestations

The main manifestations of cubital tunnel syndrome are pain, numbness and/or tingling. Pain and paresthesia in the lateral part of the shoulder, spreading to the little finger and half of the ring finger. Unpleasant sensations and pain occur at the beginning of the disease only with pressure on the elbow or after prolonged exercise. In a more severe stage, pain and numbness accompany the patient constantly. Another symptom of the disease is weakness in the arm. In advanced stages, the hand on the sore arm begins to lose weight, and pits appear between the bones due to muscle atrophy.

Diagnostics

In the early stages of the disease, the only manifestation (besides weakness of the forearm muscles) may be loss of sensation on the ulnar side of the little finger.

If the clinical picture is blurred, functional tests can help verify the diagnosis of Cubital Tunnel Syndrome, such as Tinel's test, the equivalent of Phalen's symptom - sharp flexion of the elbow will cause paresthesia in the ring and little fingers, Frohman's test, Wartenberg's test.

In some cases, it is necessary to conduct electroneuromyography (the speed of impulses along the nerve) to clarify the level of nerve damage. Nerve damage, space-occupying lesions or other pathological changes causing carpal tunnel syndrome can also be determined using ultrasound and magnetic resonance imaging, which is a more accurate and detailed study.

Treatment

At the initial stages of the disease, conservative treatment is carried out, aimed at maximizing the reduction of the load on the elbow. It is recommended to fix the elbow joint in an extension position at night using orthoses, or to splint it, which, according to recent studies, is quite comparable in effectiveness to the effectiveness of hormone injections and surgical operations. In our country, these devices are already used by traumatologists; They have not yet been introduced into neurological practice.

There are several techniques for surgical release of the nerve, but they all involve displacing the nerve anteriorly from the internal epicondyle. After surgery, treatment is prescribed aimed at restoring conduction along the nerve.

References 1. Al-Zamil M.H. Carpal syndrome. Clinical neurology. – 2008. – No. 1. – p.41–45 2. Berzins Yu. E., Dumbere R. T. Tunnel lesions of the nerves of the upper limb. Riga: Zinatne, 1989. P. 212. 3. Zhulev N.M. Neuropathies: a guide for doctors. – St. Petersburg: St. Petersburg Publishing House. – 2005. – P.416 4. Levin O.S. "Polyneuropathy", MIA, 2005

Author:

Anastasia Aleksandrovna Chernyshova, researcher at the Research Center for OZD of the Management Company "MRI Expert and Clinic Expert"

Change the usual locomotor stereotype and lifestyle

Tunnel syndromes are often the result not only of monotonous activity, but also of ergonomic disorders (improper posture, awkward position of the limb during work). Special exercises and recommendations for optimal organization of the workplace have been developed. To relieve pain and prevent relapse, orthoses and splints using the splinting principle are used. In rare cases, you have to change your profession. Training in special exercises and physical therapy are an important component of the treatment of tunnel neuropathies at the final stage of therapy.

Pain therapy

Physical influences (cold, heat).
In mild cases, ice compresses and sometimes “hot” compresses can help reduce pain. A doctor is usually consulted when these or other “home” methods “do not help.” • Anti-inflammatory therapy. Traditionally, for carpal tunnel syndromes, NSAIDs with a more pronounced analgesic and anti-inflammatory effect (diclofenac, ibuprofen) are used. It should be remembered that with long-term use of drugs in this group there is a risk of gastrointestinal and cardiovascular complications. In this regard, for moderate or severe pain, it is advisable to use a combination of low doses of the opioid analgesic tramadol (37.5 mg) and the safest analgesic/antipyretic paracetamol (325 mg). Thanks to this combination, a multiple increase in the general analgesic effect is achieved with a lower risk of side effects.

• Impact on the neuropathic component of pain. Often, with tunnel syndromes, the use of analgesics and NSAIDs is ineffective (it is in these cases that patients consult a doctor). This may be due to the fact that the dominant role in the formation of pain is played not by the nociceptive, but by the neuropathic mechanism. When pain is the result of neuropathic changes, it is necessary to prescribe drugs recommended for the treatment of neuropathic pain: anticonvulsants (pregabalin, gabapentin), antidepressants (venlafaxine, duloxetine), plates with 5% lidocaine. The choice of a particular drug should be made taking into account the clinical manifestations and individual characteristics of the patient (the possibility of developing side effects). It is important to inform the patient that drugs used for neuropathic pain, unlike “classical painkillers,” do not begin to act immediately (it is necessary to titrate the dose; the effect occurs several days or even weeks after starting the drug).

• Injections of anesthetic + hormones. A very effective and acceptable treatment method for most types of tunnel neuropathies is a blockade with the introduction of an anesthetic (Novocaine) and a hormone (hydrocortisone) into the area of ​​infringement. Special guidelines describe techniques and doses of drugs for various tunnel syndromes [Zhulev N.M., 2005]. This procedure is usually resorted to if other measures are ineffective (cold compresses, the use of analgesics, NSAIDs), but in some cases, if the patient comes at a more advanced stage of the disease and experiences severe pain, it is advisable to immediately offer such a patient this manipulation.

• Other methods of pain relief. Currently, there are reports of the high effectiveness of injection of meloxicam with hydrocortisone into the tunnel area. An effective way to reduce pain and inflammation is electrophoresis, phonophoresis with dimexide and other anesthetics. They can be carried out in a clinic setting. Symptomatic treatment. For tunnel syndromes, decongestants, antioxidants, muscle relaxants, and drugs that improve the trophism and functioning of the nerve (ipidacrine, vitamins, etc.) are also used.

Surgical intervention. Surgical treatment is usually resorted to when other options for helping the patient have been exhausted. At the same time, for certain indications, it is advisable to immediately offer the patient surgical intervention. Surgery usually involves releasing the nerve from compression, “reconstructing the tunnel.” According to statistics, the effectiveness of surgical and conservative treatment does not differ significantly a year later (after the start of treatment or surgery). Therefore, after a successful surgical operation, it is important to remember about other measures that must be followed to achieve a full recovery (prevention of relapses): changing locomotor patterns, using devices that protect against stress (orthoses, splints, bandages), performing special exercises.

Carpal tunnel syndrome

Carpal tunnel syndrome (carpal tunnel syndrome) is the most common form of compression-ischemic neuropathy encountered in clinical practice. In the population, carpal tunnel syndrome occurs in 3% of women and 2% of men [Berzins Yu.E., 1989]. This syndrome is caused by compression of the median nerve as it passes through the carpal tunnel under the transverse carpal ligament. The exact cause of carpal tunnel syndrome is not known. The following factors most often contribute to compression of the median nerve in the wrist area: • Trauma (accompanied by local swelling, tendon stretching). • Ergonomic factors. Chronic microtraumatization (often found among construction workers), microtraumatization associated with frequent repeated movements (among typists, with constant long-term work with a computer). • Diseases and conditions accompanied by metabolic disorders, edema, tendon and bone deformities (rheumatoid arthritis, diabetes mellitus, hypothyroidism, acromegaly, amyloidosis, pregnancy). • Massive formations of the median nerve itself (neurofibroma, schwannoma) or outside it in the wrist area (hemangioma, lipoma).

Carpal tunnel syndrome

This is the most common tunnel syndrome, where the median nerve is compressed at the wrist. Women suffer from it 3 times more often than men due to the fact that they have a much smaller bone canal for the nerve than men. This syndrome can develop not only from injuries and injuries, but also after removal of the mammary glands for cancer. In women who have undergone surgery, lymph circulation is poor, and the carpal tunnel is very swollen. Severe swelling can also appear in this place during pregnancy, menopause or menopause.

Diseases and hormonal changes are predisposing factors that “set the stage” for nerve compression. The immediate impetus is monotonous movements repeated day after day for several years. Movements of the hand are most often uncomfortable, unphysiological, and cause the muscles to become too tense. As a rule, these are movements necessary in a certain profession. Seamstresses, polishers, and musicians suffer. In recent years, the carpal tunnel has become increasingly affected by programmers who regularly press buttons on a computer keyboard.

Clinical manifestations

Carpal tunnel syndrome is characterized by pain, numbness, paresthesia and weakness in the arm and hand.
Pain and numbness extend to the palmar surface of the thumb, index, middle and 1/2 ring finger, as well as to the dorsum of the index and middle finger. Initially, symptoms occur when performing any activities using a brush (working on a computer, drawing, driving), then numbness and pain appear at rest, sometimes occurring at night. The following tests are suggested to verify the diagnosis of carpal tunnel syndrome. Tinel test: tapping the wrist (above the median nerve) with a neurological hammer causes a tingling sensation in the fingers or pain radiating (electrical shooting) to the fingers (Fig. 2). Pain may also be felt in the tapping area. A positive Tinel sign is found in 26–73% of patients with carpal tunnel syndrome [Al Zamil M.H., 2008]. Durkan's test: compression of the wrist in the area of ​​the median nerve causes numbness and/or pain in the 1st–3rd, half of the 4th fingers (as with Tinel's symptom). Phalen Test: Wrist flexion (or extension) 90 degrees produces numbness, tingling, or pain in less than 60 seconds (Figure 3). A healthy person may also develop similar sensations, but not earlier than after 1 minute. Opposition test: with severe thenar weakness (which occurs at a later stage), the patient cannot connect the thumb and little finger (Fig. 4); or the doctor (researcher) can easily separate the patient’s closed thumb and little finger.

Henry Ford Disease, or Carpal Tunnel Syndrome

As Engels said, labor made a man out of a monkey. And monotonous work - the same one, the organization of which allowed Henry Ford with his assembly line to become a very rich man - led not only to an increase in production, but also to the emergence of specific diseases.

It is not at all surprising that builders often suffer from arthrosis of the shoulder joint, surgeons who spend many hours tensely at the operating table from varicose veins, and office workers from carpal tunnel syndrome, which is also known as carpal tunnel syndrome.

What is carpal tunnel syndrome?

Scientists claim that there is no special connection between using a mouse with a keyboard and the appearance of characteristic pain in the hand: they say, along with white-collar workers, pianists, seamstresses, and even sign language interpreters also suffer from carpal tunnel syndrome. Nevertheless, hammering on keys for many hours certainly does not improve your health.

Carpal (carpal) tunnel syndrome occurs when one of the three nerves responsible for the mobility and sensitivity of the hand - the median - becomes pinched in the wrist area, on the back of the hand. This occurs due to a combination of two factors - the genetically determined anatomical narrowness of the carpal tunnel and the long stay of the hand in an unnatural position.

"De-energized" hand

We all know the problem of a broken phone or laptop charging cable: one fine day you notice that due to constant kinks at the base of the cord, the braiding has burst, which means it’s time to go to the store for a new one or, armed with electrical tape, try to temporarily postpone the purchase .

Approximately the same situation occurs when you methodically compress the median nerve during work year after year: the first symptom, as a rule, is discomfort in the pads of the thumb, index and middle fingers. It can be aching pain, tingling, numbness, or even a kind of “shooting” - as if the hand is being shocked. Some patients note that it is as if a tight bracelet is locked around the wrist, which limits the mobility of the hand.

During periods of exacerbation, a person experiences problems with usual actions - he cannot comfortably pick up a spoon while eating, transfers his mobile phone to the other hand while talking, refuses to sew because he cannot thread the needle. Shaking the limb brings temporary relief, but after a few minutes or hours the discomfort returns, sometimes even preventing sleep.

In severe cases, tunnel syndrome can lead to atrophy of the thumb muscles, making it impossible to even hold an object in the affected hand. In this case, the disease usually affects the dominant hand - the right hand in right-handed people and the left hand in left-handed people.

Diagnosis is a delicate matter

Even if you find yourself with symptoms characteristic of carpal tunnel syndrome, do not rush to label yourself as “disabled office worker” and go on an Internet search for quick treatment. If your hands become numb or you experience discomfort, this may be caused by other diseases that have nothing to do with compression of the median nerve. For example, inflammation of the wrist joint or tumor. Therefore, if pain and problems with hand mobility and sensitivity occur, it is important to make an appointment with a neurologist as soon as possible.

And here we are faced with a popular problem in domestic medicine: you will be diagnosed without problems (although you will most likely have to pay for electroneuromyography and MRI of the joint yourself), but the prospects for treatment will be vague.

And it’s not that neurologists haven’t learned how to treat carpal tunnel syndrome—it’s just that few patients decide to make a radical change in activity, even if only for the sake of their own health. And since this pathology has not yet been classified as an occupational hazard, you should not count on an official transfer to another position while maintaining the same salary.

Therapeutic measures: radical and not so radical

If you are not ready to take a time-out of several months or retrain as an ambidexter, then you need to approach treatment responsibly. First, deal with unpleasant symptoms: drugs from the group of non-steroidal anti-inflammatory drugs will help for this. They will relieve inflammatory swelling of the nerve and numb the problem area. But don’t get carried away with ibuprofen and the like: this is only a temporary measure of help.

The most important thing is to eliminate the cause of the “break” of the nerve. To do this, it is necessary that the hand and forearm be in the same plane while working. That is, either pick up a flat computer mouse, or make it a rule to place a cushion under your arm to level the position of the limb.

By the way, a good move would be to buy an orthosis that fixes the wrist in one position. There is no need to wear it around the clock - only during work that caused carpal tunnel syndrome. Physiotherapy and massage will also ease the symptoms of carpal tunnel syndrome, but remember that warming up the wrist should only be done with the approval of a doctor and without exacerbation of the disease.

To restore nerve fibers, your doctor may prescribe you injections of a drug containing vitamin B6 - do not ignore this recommendation, because the process of restoring the median nerve will take more than one month. Of course, there is a lot of this compound in cereals, walnuts, bananas and seafood, but it is unlikely that diet correction will help on its own, although in combination with other approaches it will certainly be useful.

The last resort in the treatment of carpal tunnel syndrome is surgery - during the operation, the doctor cuts the tissue of the wrist at the base of the palm, and then the transverse carpal ligament, which allows the nerve to be freed from its anatomical “captivity”.

Despite the apparent simplicity of this solution, you need to be prepared for a long recovery period and possible side effects: sometimes after surgery on the hand, patients complain of chronic weakness in the hand, which prevents them from performing usual actions with the same dexterity.

***

Finally, a few words about prevention. The idea of ​​limiting time spent at the computer seems blasphemous to almost every modern person, so it is more appropriate to solve the issue of strengthening the ligaments and tendons of the hands. Pull-ups on the horizontal bar, jumping rope and the now so popular plank exercise will help you avoid the unpleasant consequences of carpal tunnel syndrome. And for fun, you can try using a graphics tablet instead of a mouse - after all, scientists have long proven the beneficial effects of handwriting on brain function!

Olga Kashubina

Photo thinkstockphotos.com

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Differential diagnosis

Carpal tunnel syndrome should be differentiated from arthritis of the carpo-metacarpal joint of the thumb, cervical radiculopathy, and diabetic polyneuropathy. Patients with arthritis will show characteristic bone changes on x-rays. In cervical radiculopathy, reflex, sensory and motor changes will be associated with neck pain, while in carpal tunnel syndrome these changes are limited to distal manifestations. Diabetic polyneuropathy is usually a bilateral, symmetrical process involving other nerves (not just the median nerve). At the same time, a combination of polyneuropathy and carpal tunnel syndrome in diabetes mellitus cannot be ruled out.

Treatment

In mild cases of carpal tunnel syndrome, ice compresses and a decrease in load can help. If this does not help, the following measures must be taken: 1. Immobilization of the wrist. There are special devices (splints, orthoses) that immobilize the wrist and are convenient to use (Fig. 1). Immobilization should be carried out at least overnight, and preferably for 24 hours (at least in the acute period). 2. NSAIDs. Drugs from the NSAID group will be effective if the inflammatory process dominates in the pain mechanism. 3. If the use of NSAIDs turns out to be ineffective, it is advisable to inject novocaine with hydrocortisone into the wrist area. As a rule, this procedure is very effective. 4. In outpatient settings, electrophoresis can be performed with anesthetics and corticosteroids. 5. Surgical treatment. For mild or moderate carpal tunnel syndrome, conservative treatment is more effective. In cases where all conservative treatment options have been exhausted, surgical treatment is resorted to. Surgical treatment consists of partial or complete resection of the transverse ligament and releasing the median nerve from compression. Recently, endoscopic surgical methods have been successfully used in the treatment of carpal syndrome.

Pronator teres syndrome (Seyfarth syndrome)

Entrapment of the median nerve in the proximal part of the forearm between the pronator teres fascicles is called pronator syndrome.
This syndrome usually begins to appear after significant muscle activity over many hours involving the pronator and flexor digitorum muscles. Such types of activities are often found among musicians (pianists, violinists, flutists, and especially often among guitarists), dentists, and athletes [Zhulev N.M., 2005]. Long-term tissue compression is of great importance in the development of pronator teres syndrome. This can happen, for example, during deep sleep when the newlywed’s head is positioned for a long time on the partner’s forearm or shoulder. In this case, the median nerve in the pronator snuffbox is compressed, or the radial nerve in the spiral canal is compressed when the partner’s head is located on the outer surface of the shoulder (see radial nerve compression syndrome at the level of the middle third of the shoulder). In this regard, to designate this syndrome in foreign literature, the terms “honeymoon paralysis” (honeymoon paralysis, newlywed paralysis) and “lovers paralysis” (lovers paralysis) have been adopted. Pronator teres syndrome sometimes occurs in nursing mothers. In them, compression of the nerve in the area of ​​the pronator teres occurs when the baby’s head lies on the forearm, he is breastfed, lulled to sleep, and the sleeping person is left in this position for a long time.

Cubital Tunnel Syndrome, Part I - Description

Nerve compression is a common cause of pain and dysfunction in the upper extremities. Most often, such problems occur in people for whom their hands are working tools - from an office worker to a massage therapist. The features of cubital tunnel syndrome are not as widely reflected in the literature as the features of carpal tunnel syndrome, but both of these problems occur in practice with almost the same frequency.

Cubital tunnel syndrome is the second most common type of compression neuropathy of peripheral nerves. It occurs when the ulnar nerve is compressed between the two heads of the flexor carpi ulnaris muscle at the back of the elbow, in an area called the cubital tunnel.

Description

The cubital tunnel is located at the back of the elbow and is bounded by the two heads of the flexor carpi ulnaris muscle. One of the heads of the flexor carpi ulnaris originates from the attachments of the common flexor tendon at the medial epicondyle of the humerus. The second head arises from the medial part of the olecranon process. These two heads further unite to form the belly of the flexor carpi ulnaris.

The nerve passes between the two heads of the muscle. The space in the cubital tunnel can decrease by up to 55 percent when the elbow flexes, increasing the likelihood of nerve compression. In addition, when the arm is bent at the elbow, the ulnar nerve is stretched, which can cause exacerbation of symptoms in existing cubital tunnel syndrome. Also, when the arm is bent at the elbow, the position of the ulnar nerve may change, which can also cause pain and other neuropathy syndromes.

Cubital tunnel syndrome can develop as a result of physical impact on the elbow (most often compression, both acute and chronic), valgus deformation of the elbow joint, the presence of bone spurs, synovial cysts, muscle fibrosis, as well as mechanical compression of the nerve when the arm is flexed at the elbow.

The most common cause of cubital tunnel syndrome is hypertonicity of the flexor carpi ulnaris muscle. The ulnar nerve in this area may be more sensitive to compression in the presence of other pathologies associated with its compression in more proximal areas, for example, with compression syndrome of the superior thoracic outlet.

Cubital tunnel syndrome usually causes a complex neuralgic symptom complex, including pain, burning, tingling or paresthesia. In addition, motor symptoms may also appear - atrophy and weakness, usually affecting the internal muscles of the arm - with cubital tunnel syndrome, the symptoms described above are localized in these muscles more often than in other muscles of the forearm innervated by the ulnar nerve.

Whitney Lowe

Clinical manifestations

With the development of pronator teres syndrome, the patient complains of pain and burning 4–5 cm below the elbow joint, along the anterior surface of the forearm and pain radiating to the 1st–4th fingers and palm.
Tinel's syndrome. In case of pronator teres syndrome, Tinel's sign will be positive when tapping with a neurological hammer in the area of ​​the pronator snuff box (on the inside of the forearm). Pronator-flexor test. Pronating the forearm with a tightly clenched fist while creating resistance to this movement (counteraction) leads to increased pain. Increased pain can also be observed when writing (prototype of this test). When examining sensitivity, a sensitivity disorder is revealed, involving the palmar surface of the first three and a half fingers and the palm. The sensory branch of the median nerve, innervating the palmar surface of the hand, usually passes above the transverse carpal ligament. The occurrence of sensory disturbances on the palmar surface of the first finger, the dorsal and palmar surfaces of the second and fourth fingers, with preservation of sensitivity in the palm, allows one to confidently differentiate carpal tunnel syndrome from pronator teres syndrome. Thenar atrophy in pronator teres syndrome is usually not as severe as in progressive carpal tunnel syndromes.

Symptoms

Numbness on the inside of the forearm, hand, and 4th and 5th fingers is the early and most common symptom of cubital tunnel syndrome. If the traumatic effect on the nerve continues, then numbness is accompanied by nagging pain from the inner epicondyle of the shoulder along the inner surface of the forearm to the hand. The accuracy of movements of the fingers and, especially, the first finger of the hand begins to suffer, since the nerve is responsible for the innervation of the muscles of the hand. Manifestations of pain and numbness are aggravated by bending the arm at the elbow joint. In this position, as mentioned above, the nerve is stretched. Cubital tunnel syndrome is especially aggravated by prolonged flexion of the arm at the elbow joint, such as when talking on the phone or while sleeping.

When pressing or slightly impacting the area of ​​the ulnar nerve groove, a tingling sensation or even a shooting sensation may appear up to the little finger. This is called Tinel's sign.

Supracondylar process syndrome of the shoulder (Strother's band syndrome, Coulomb, Lord and Bedossier syndrome)

In the population, in 0.5–1% of cases, a variant of the development of the humerus is observed, in which a “spur” or supracondylar process (apophysis) is found on its distal anteromedial surface. Due to the accessory process, the median nerve is displaced and stretched (like a bowstring). This makes him vulnerable to defeat. This tunnel syndrome, described in 1963 by Coulomb, Lord and Bedossier, has almost complete similarities with the clinical manifestations of pronator teres syndrome: pain, paresthesia, and decreased flexion strength of the hand and fingers are detected in the zone of innervation of the median nerve. In contrast to pronator teres syndrome, when the median nerve is damaged under Strather's ligament, mechanical compression of the brachial artery with corresponding vascular disorders is possible, as well as severe weakness of the pronator teres (teres and minor). The following test is useful in diagnosing supracondylar process syndrome. When extending the forearm and pronation in combination with formed flexion of the fingers, painful sensations are provoked with localization characteristic of compression of the median nerve. If it is suspected that the compression is caused by a “spur” of the humerus, an x-ray examination is indicated. Treatment involves resection of the supracondylar process (“spur”) of the humerus and ligament.

Cubital tunnel syndrome

Cubital tunnel syndrome (Sulcus Ulnaris Syndrome) is compression of the ulnar nerve in the cubital canal (Mouchet's canal) in the area of ​​the elbow joint between the internal epicondyle of the humerus and the ulna bone and is the second most common after carpal tunnel syndrome. Cubital tunnel syndrome develops for a number of reasons. Cubital tunnel syndrome can be caused by repetitive bending of the elbow joint. Therefore, cubital tunnel syndrome is classified as a disorder called accumulated trauma disorder (overuse syndrome). Those. the disorder may occur during normal, repetitive movements (most often associated with a specific occupational activity) in the absence of obvious traumatic injury. Direct trauma can also contribute to the development of cubital tunnel syndrome, such as leaning on the elbow while sitting. Patients with diabetes and alcoholism are at greater risk of developing cubital tunnel syndrome.

Surgery options for cubital tunnel syndrome

The syndrome belongs to the group of compression-ischemic neuropathies. The very first symptoms are pain and problems with movement, as nerve function is impaired. First, disorders arise, after which the problem is aggravated by a decrease in muscle strength. Based on the reasons, motor and sensory disorders can occur simultaneously.

There are two types of syndromes:

Cubital tunnel syndrome

The main symptoms of this syndrome are:

• pain in the area of ​​the ulnar fossa, which radiates to the forearm;
• burning, tingling, twitching;
• pain worsens at night and when moving the elbow joint;
• over time, the pain intensifies; decreased sensitivity in the elbow joint;
• movement disorders and muscle weakness;
• the hand begins to lose weight due to muscle atrophy;
• deformation of the hand occurs.

Guyon's canal syndrome (ulnar carpal syndrome)

The symptoms are largely similar to the previous syndrome, but there are some differences in presentation:

• pain in the area of ​​the wrist joint;
• pain intensifies when moving the hand;
• decreased sensitivity in the area of ​​the ring and little fingers;
• motor disorders of the ring and little fingers;
• the brush may take on the appearance of a “bird’s foot”;
• muscular atrophy of the hand.

If the primary symptoms of the disease are ignored, the symptoms can be combined and confused due to the fact that the nerve will be increasingly subject to compression. The presence of neuropathy in the elbow joint can be determined by tapping a neurological hammer in the place where, in the opinion of a specialist, it is compressed.

If the main cause is gradual compression of the nerve, and the symptoms have appeared recently, then first of all they begin conservative treatment methods (medicines, traditional medicine) and only if there is no result, they begin surgical intervention due to the ineffectiveness of conservative treatment.

Clinical manifestations

The main symptoms of cubital tunnel syndrome are pain, numbness and/or tingling. Pain and paresthesia are felt in the lateral part of the shoulder and radiate to the little finger and half of the fourth finger. At first, discomfort and pain occur only when pressure is applied to the elbow or after prolonged bending. In a more severe stage, pain and numbness are felt constantly. Another sign of the disease is weakness in the arm. It manifests itself as a loss of “confidence” in the hand: suddenly objects begin to fall out of it during some habitual actions. For example, it becomes difficult for a person to pour water from a kettle. In advanced stages, the hand on the sore arm begins to lose weight, and pits appear between the bones due to muscle atrophy.

Before you treat ulnar tunnel syndrome

It is very important to conduct a full differential diagnosis before treating cubital tunnel syndrome. It all starts with a visit to an experienced neurologist. He performs functional diagnostic tests, palpates the upper limb and finds points of compression of the nerve fiber. The doctor may then order different types of tests. Most often, before treating ulnar nerve tunnel syndrome, electroneuromyography, radiography, ultrasonography, and magnetic resonance imaging are used.

These tests can diagnose cubital tunnel syndrome and identify potential causes of its development. After assessing the condition of all tissues, the doctor begins to develop an individual course of treatment.

Diagnostics

In the early stages of the disease, the only manifestation (besides weakness of the forearm muscles) may be loss of sensation on the ulnar side of the little finger. If the clinical picture is blurred, the following tests can help verify the diagnosis of Cubital Tunnel Syndrome: Tinel test - the occurrence of pain in the lateral part of the shoulder, radiating to the ring finger and little finger when tapping with a hammer over the area where the nerve passes in the area of ​​the medial epicondyle. Equivalent to Phalen's sign, sudden flexion of the elbow will cause paresthesia in the ring and little fingers. Frohman's test. Because of weakness of the abductor policis brevis and flexor policis brevis, excessive flexion of the interphalangeal joint of the thumb on the affected hand may be detected in response to a request to hold a paper between the thumb and index finger (Figure 5). Wartenberg test. Patients with more severe muscle weakness may complain that when putting their hand in a pocket, the little finger is pulled to the side (does not fit into the pocket) (Fig. 6).

Symptoms of ulnar nerve tunnel syndrome

The first clinical symptoms of cubital tunnel syndrome begin to appear immediately after the development of the pathology. They may include the following signs:

• pain that is accompanied by numbness in the elbow, spreading along the forearm and to the shoulder joint;
• tingling sensation, especially strong in the ring finger and little finger;
• weakening of muscle efforts in the ring and little fingers;
• reduction in the ability to squeeze the fingers tightly;
• gradually muscle strength in the hand decreases and the patient loses the ability to perform self-care or minor operations;
• in advanced clinical cases, partial or complete atrophy of the arm muscles is observed;
• in the absence of timely, comprehensive treatment, deformation of the hand begins, due to the development of ankylosis and contractures.

If you have symptoms of ulnar nerve tunnel syndrome, immediately consult a neurologist. The specialist will conduct an examination and make an accurate diagnosis. He will be able to find the exact cause of the development of symptoms of elbow tunnel syndrome and give individual recommendations to eliminate their impact.

Remember that the symptoms of cubital tunnel syndrome will not go away on their own. Over time, the pathology will continue to develop. Clinical manifestations will only get worse. There will come a time when you will have to undergo surgery to restore the function of the affected upper limb. Don't let your situation get to this point. Contact your doctor promptly. Moreover, in Moscow there is a great opportunity to visit a neurologist in our manual therapy clinic completely free of charge. Take advantage of this opportunity to make an appointment using the special form that you will find at the end of this page.

Treatment

At the initial stages of the disease, conservative treatment is carried out.
Changing the load on the elbow and eliminating elbow flexion as much as possible can significantly reduce pressure on the nerve. It is recommended to fix the elbow joint in an extension position at night with the help of orthoses, hold the car steering wheel with your arms straightened at the elbows, straighten the elbow when using a computer mouse, etc. If the use of traditional drugs (NSAIDs, COX-2 inhibitors, splinting) for 1 week does not have a positive effect, an injection of an anesthetic with hydrocortisone is recommended. If the effectiveness of these measures is insufficient, then an operation is performed. There are several techniques for surgical release of the nerve, but all of them in one way or another involve moving the nerve anteriorly from the internal epicondyle. After surgery, treatment is prescribed aimed at quickly restoring nerve conduction. Guyon's tunnel syndrome Guyon's tunnel syndrome develops due to compression of the deep branch of the ulnar nerve in the canal formed by the pisiform bone, the hook of the hamate, the palmar metacarpal ligament and the palmaris brevis muscle. There are burning pains and sensitivity disorders in the 4th–5th fingers, difficulty in pinching movements, adduction and extension of the fingers.

Tunnel ulnar syndrome is very often the result of prolonged pressure from working tools, for example, vibrating tools, screwdrivers, pliers, and therefore occurs more often in representatives of certain professions (gardeners, leather cutters, tailors, violinists, people working with jackhammers). Sometimes the syndrome develops after using a cane or crutch. Pathological factors that can cause compression also include enlarged lymphatic ganglia, fractures, arthrosis, arthritis, ulnar artery aneurysm, tumors and anatomical formations around Guyon's canal. Differential diagnosis. The difference between Guyon's canal syndrome and ulnar canal syndrome is indicated by the fact that when a nerve is damaged in the hand area, pain occurs in the hypothenar and base of the hand, as well as intensification and irradiation in the distal direction during provoking tests. In this case, sensitivity disorders occupy only the palmar surface of the 4th–5th fingers. On the back of the hand, sensitivity is not impaired, since it is provided by the dorsal branch of the ulnar nerve, which arises from the main trunk at the level of the distal third of the forearm.

When making a differential diagnosis with radicular syndrome (C8), it should be taken into account that paresthesia and sensitivity disorders can also appear along the ulnar edge of the hand. Paresis and hypotrophy of the hypothenar muscles are possible. But with C8 radicular syndrome, the zone of sensory disorders is much larger than with Guyon’s canal, and there is no hypotrophy and paresis of the interosseous muscles. If the diagnosis is made early, limiting activity may help. Patients can be recommended to use fixators (orthoses, splints) at night or during the day to reduce trauma. If conservative measures fail, surgical treatment is performed aimed at reconstructing the canal in order to free the nerve from compression.

Surgical treatment

If improvement cannot be achieved with conservative treatment, then surgical treatment should be considered. This will avoid further trauma to the ulnar nerve. The goal of surgery for cubital tunnel syndrome is to relieve excess pressure on the nerve. An incision is made along the inside of the elbow joint and forearm in the projection of the internal epicondyle of the shoulder.

Transposition of the ulnar nerve

One surgical treatment method is called ulnar nerve transposition. During this operation, the surgeon isolates the ulnar nerve and moves it to the anterior surface of the elbow joint. In the future, the nerve is not stretched when the arm is extended.

Medial epicondylectomy

With this method of surgical treatment, economical resection of the internal epicondyle of the shoulder is performed. This method is used extremely rarely. It may be recommended in cases where ossifications (bone growths) or osteophytes (bone spurs) develop in the area of ​​the internal epicondyle. Bone formations compressing the ulnar nerve are resected. The operation can be performed under general anesthesia (anesthesia) or regional anesthesia. Regional anesthesia allows you to numb only the entire upper limb.

Radial nerve compression syndrome

Three variants of compression damage to the radial nerve can be distinguished: 1. Compression in the armpit area.
Rarely seen. It occurs as a result of the use of a crutch (“crutch paralysis”), and paralysis of the extensors of the forearm, hand, main phalanges of the fingers, abductor pollicis muscle, and supinator develops. The flexion of the forearm is weakened, the reflex from the triceps muscle fades. Sensitivity is lost on the dorsal surface of the shoulder, forearm, and partly the hand and fingers. 2. Compression at the level of the middle third of the shoulder (spiral canal syndrome, “Saturday night paralysis”, “park bench”, “bench” syndrome). It occurs much more often. The radial nerve, emerging from the axillary region, bends around the humerus, where it is located in the bony spiral groove (groove), which becomes the musculoskeletal tunnel, since the two heads of the triceps muscle are attached to this groove. During the period of contraction of this muscle, the nerve is displaced along the humerus and as a result can be injured during forced repeated movements in the shoulder and elbow joints. But most often, compression occurs due to compression of the nerve on the outer-posterior surface of the shoulder. This usually occurs during deep sleep (deep sleep often occurs after drinking alcohol, which is why it is called “Saturday night syndrome”), in the absence of a soft bed (“park bench syndrome”). Pressure on the nerve may be due to the location of the partner's head on the outer surface of the shoulder. 3. Compressive neuropathy of the deep (posterior) branch of the radial nerve in the subulnar region (supinator syndrome, Froese syndrome, Thomson-Kopell syndrome, “tennis elbow” syndrome). Tennis elbow, tennis elbow, or epicondyllitis of the lateral epicondyle of the humerus is a chronic disease caused by a degenerative process in the area of ​​muscle attachment to the lateral epicondyle of the humerus. Compression syndrome of the posterior (deep) branch of the radial nerve under the aponeurotic edge of the short extensor carpi radialis or in the tunnel between the superficial and deep bundles of the supinator muscle of the forearm can be caused by muscle overload with the development of myofasciopathies or pathological changes in perineural tissues. It manifests itself as pain in the extensor muscles of the forearm, their weakness and hypotrophy. Dorsal flexion and supination of the hand, active extension of the fingers against resistance provoke pain. Active extension of the third finger while pressing it and simultaneously straightening the arm at the elbow joint causes intense pain in the elbow and upper forearm. Treatment includes general etiotropic therapy and local effects. Take into account the possible connection of tunnel syndrome with rheumatism, brucellosis, arthrosis of metabolic origin, hormonal disorders and other conditions that contribute to compression of the nerve by surrounding tissues. Anesthetics and glucocorticoids are injected locally into the area of ​​the pinched nerve. Complex treatment includes physical therapy, the prescription of vasoactive, decongestant and nootropic drugs, antihypoxants and antioxidants, muscle relaxants, ganglion blockers, etc. Surgical decompression with dissection of the tissues compressing the nerve is indicated if conservative treatment is unsuccessful. Thus, hand tunnel syndromes are a type of damage to the peripheral nervous system caused by both endogenous and exogenous influences. The outcome depends on the timeliness and adequacy of treatment, correct preventive recommendations, and the patient’s orientation in choosing or changing a profession that predisposes to the development of tunnel neuropathy.

The article uses drawings from the book by S. Waldman. Atlas of commom pain syndromes. – Saunders Elsevier. – 2008.

Treatment of ulnar nerve tunnel syndrome

In official medicine, cubital tunnel syndrome is treated with non-steroidal anti-inflammatory drugs. They temporarily eliminate the inflammatory reaction and swelling of soft tissues. The patient feels relief. However, after some time, all symptoms return. Vasodilating pharmacological drugs are also used, which enhance blood microcirculation and are designed to initiate the process of nerve fiber regeneration. For the same purpose, B vitamins in complex are prescribed.

Ulnar nerve syndrome can be more successfully treated using manual therapy methods. In this case, treatment of ulnar nerve tunnel syndrome is carried out solely with the aim of eliminating the potential cause of its development and complete regeneration of the damaged nerve fiber.

To treat cubital tunnel syndrome, our manual therapy clinic uses the following techniques:

• osteopathy to improve the processes of microcirculation of blood and lymphatic fluid in the focus of pathological tissue changes;
• massage to increase the elasticity and permeability of all soft tissues;
• physiotherapy to accelerate cellular metabolism and eliminate swelling;
• therapeutic exercises and kinesiotherapy to restore the normal structure and tone of all soft tissues of the elbow and wrist joints, the forearm and the entire upper limb as a whole;
• reflexology (acupuncture) allows you to start the process of natural regeneration by activating the hidden reserves of the human body.

The course of treatment is always developed individually. The characteristics of the patient's health condition are taken into account. If you require an individual consultation with a neurologist, you can sign up for it at our manual therapy clinic. The first appointment is free for all patients.