Case Study: Ulnar Neuropathy in the Cubital Tunnel

Our Patient

Our patient is a 53 year-old female who came to us complaining of left shoulder/neck pain, elbow pain, and numbness and tingling extending to her fourth and fifth fingers. In the two weeks prior to her visit to our clinic, her elbow pain had begun to intensify.

The Challenge

The patient had previously seen a pain management doctor who prescribed an MRI.

The MRI results revealed:

• Multilevel facet arthrosis – degeneration of the spinal facet joints
• Multiple bulging and herniated discs
• Bilateral foraminal stenosis at the junction of C6-C 7 vertebrae

She was treated with two epidural injections and three months of physical therapy, with no improvement in her condition.

Our Diagnostic Process

Clinical Exam

Our clinical exam revealed multiple issues that appeared to be contributing to the patient’s pain and dysfunction:

• Significant anterior (forward) head carriage
• Kyphosis, with protracted shoulder blades, moreso on the left side
• Inefficient breathing strategy
• Loss of intra abdominal activation
• Reduced left shoulder range of motion
• Tenderness upon palpation of the mid cervical spine, facet, and middle scalene that did not radiate to the arm or fingers

A Spurling compression test of the cervical spine did not replicate her symptoms. However, she did test positive for the Tinel sign – a pins and needle feeling elicited by tapping on the ulnar nerve at the cubital tunnel. This test reproduced her shoulder pain and mild paresthesia into her fourth and fifth digits.

High Resolution Diagnostic Ultrasonography Exam

A thorough exam of the affected tissues and structures using high resolution diagnostic ultrasound revealed multiple issues:

• Significant thickening, deformity and compression of the ulnar nerve at the neck
• Deformity of the ulnar nerve at the cubital tunnel of the elbow, with compression between the heads of the flexor carpi ulnaris – a forearm wrist flexor muscle
• Infiltration and atrophy of associated forearm muscles

Discussion

Compression and entrapment of peripheral nerves is fairly common and routinely underdiagnosed. Consequently, a neglected subclinical compressed nerve often degenerates into true neuropathy.

Multiple research studies show that nerve compression can create pain due to:

• Densification of fascia
• Changes in the neuro dynamics of the entire peripheral nerve and its roots
• Retrograde spread of of neural inflammation
• Protective reaction of muscles to reduce pressure on the nerve at the site of compression, sometimes causing muscle pain, spasms and joint subluxations

Patients presenting with musculoskeletal pain, especially pain traveling to peripheral nerves, should be examined for nerve compression, both clinically and via high resolution ultrasonography.

Herniated discs in the spine are common and do not always produce pain. However, doctors should be aware of peripheral nerve compression and entrapment, as well as double crush syndrome – peripheral nerve compression at two or more locations along the course of a nerve.

Many doctors, chiropractors and physical therapists do not have access to diagnostic ultrasonography, nor are they sufficiently trained to use it. Most rely solely on magnetic resonance imaging (MRI) to diagnose musculoskeletal pain. However, MRI does not have high enough resolution to detect compressed peripheral nerves, which are extremely common. Consequently, the patient may present with pain in distal from the site of nerve compression, leading to misdiagnosis and ineffective treatment.

A comprehensive knowledge of nerve distribution and muscle innervation, along with advanced clinical examination skills and experience with diagnostic ultrasonography, are all prerequisites for the successful diagnosis and treatment of musculoskeletal pathologies.