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Ulnar Nerve Entrapment

by Whitney Lowe

There are two locations where the ulnar nerve is likely to be compressed in the upper extremity.
The first is at the elbow in a region called the cubital tunnel; here the condition is called cubital
tunnel syndrome. The second is at the wrist as the nerve enters Guyon's canal (also known as the
tunnel of Guyon). Here, ulnar nerve entrapment is called Guyon's canal syndrome.
These two problems occur more often than we realize. In fact, cubital tunnel syndrome is considered the second-mostcommon upper-extremity peripheral-compression neuropathy, with carpal tunnel syndrome being the first. Luckily,
identification of these conditions is not terribly difficult. Massage treatment is also generally effective.
Pathology
The cubital tunnel is formed by the two heads of the flexor carpi ulnaris muscle. One head originates
at the medial epicondyle of the humerus, while the other is derived from the olecranon process. The
two heads join to form the belly of the flexor carpi ulnaris. The ulnar nerve courses between the two
heads in a channel called the cubital tunnel. Cubital tunnel syndrome occurs when the nerve is
compressed between the two heads of the muscle.
Cubital tunnel syndrome develops as either an acute or chronic injury. Though not common, acute
cubital tunnel syndrome may occur from a blow directly to the posterior elbow. As a result, scar
tissue could develop in the tunnel, creating compression. It is also possible that the blow could
damage bones or ligaments in the region that press on the nerve. The blow might also sensitize the
nerve to further pressure.
In chronic compression injuries, cubital tunnel syndrome usually develops from tightness in the flexor
carpi ulnaris muscle or prolonged periods with the elbow in flexion. During elbow flexion the two
heads of the flexor carpi ulnaris are pulled apart as the olecranon process moves slightly away from
the humerus. The tunnel becomes narrower and consequently increases pressure on the ulnar
nerve. It is common for people to experience the symptoms of ulnar nerve compression at night by
holding the elbow in flexion for long periods during sleep.
The mechanism of damage in Guyons canal syndrome is somewhat different. Guyon's canal is
located in the wrist, adjacent to the carpal tunnel. Like the carpal tunnel, Guyon's canal is
bordered by the transverse carpal ligament (also called the flexor retinaculum). There is a
division in the ligament near the ulnar side of the hand that creates Guyon's canal (see Figure
2). The ulnar nerve and artery pass through Guyon's canal. Unlike the carpal tunnel, there are
no tendons that travel through Guyon's canal. Therefore pressure on the nerve from
tenosynovitis does not occur in Guyons canal syndrome as it does in carpal tunnel syndrome.

Because there are no tendons in the canal to press on the nerve, pathological compression in
Guyons canal syndrome occurs from extrinsic factors. That means nerve compression occurs
from forces outside the canal as opposed to pressure from within. A condition like carpal tunnel
syndrome, on the other hand, involves intrinsic pressure because it comes from within the tunnel due to tendon swelling.
Guyon's canal syndrome may occur as either an acute or chronic compression neuropathy. Acute injuries occur most
often when the base of the hand is hit while the wrist is in hyperextension. Falling on an outstretched hand is a good
example. Chronic compression injuries occur from pressure maintained on the base of the hand for long periods. A
common example is long-distance cycling, where the weight of the body is resting on the handlebars with the wrist in
hyperextension. In the cycling community Guyons canal syndrome is referred to as handlebar palsy.

Assessment and evaluation

The symptoms of ulnar nerve compression in the two syndromes are similar even though
the pathologies occur in different locations. Clients usually report pain, numbness and/or
paresthesia in the ulnar nerve distribution of the hand (see hand illustration). It is important
to isolate the sensory symptoms to the ulnar nerve distribution because many people
assume they have carpal tunnel syndrome with neurological symptoms in the hand.
Weakness in muscles supplied by the ulnar nerve may also occur in both conditions.
While the ulnar nerve innervates a number of muscles in the forearm, motor weakness is
most evident in muscles of the hand, such as the adductor pollices. It is an important
muscle in grasping objects. Consequently, the client may report difficulty in holding objects
in the hand, or clumsiness when performing precision activities such as writing.
While many symptoms of these two peripheral neuropathies are similar, there are a number of factors that help distinguish
them in the evaluation process. If the symptoms started from an acute injury, identify whether the primary insult was to the
elbow or the wrist. In chronic compression pathologies it is a little more complex, but a more thorough assessment
provides valuable clues.
If the symptoms are aggravated by long periods with the body weight resting on the wrist, especially if it is in a
hyperextended position, Guyons canal syndrome is implicated. Using a cane for walking is an example of how chronic
compression may occur in Guyon's canal. If the symptoms occur from long periods of resting the body weight on the
elbows, or holding the elbows in a flexed position (not necessarily weight-bearing) for long periods, then cubital tunnel
syndrome is more likely.
There are a few visual indicators that may help identify ulnar nerve compression from either cubital
tunnel syndrome or Guyons canal syndrome. As mentioned above, the ulnar nerve innervates
several muscles in the hand. Compression of the nerve in either condition may lead to atrophy of the
hypothenar muscles (those located in the fleshy bundle on the ulnar side of the hand). In some
cases, cubital tunnel syndrome is aggravated by a postural distortion of the upper extremity called
cubital valgus (see Figure 2). In cubital valgus the nerve may be pulled taut against structures
bordering it within the cubital tunnel.
Palpation is helpful for identifying both conditions. Because the region of entrapment is superficial in
both pathologies, palpating the involved area may increase symptoms. If manual pressure directly
over the cubital tunnel reproduces the primary complaint, then cubital tunnel syndrome is likely.
Similarly, if pressure directly over Guyon's canal reproduces the complaint, Guyons canal syndrome
is implicated.
The neurological symptoms of cubital tunnel syndrome or Guyons canal syndrome are apt to be reproduced with certain
motions of the upper extremity. If cubital tunnel syndrome is the primary problem, neurological sensations may be
reproduced with elbow flexion either passively or actively. Often the symptoms are not aggravated by simply moving the
elbow into a flexed position. The elbow must be held in the flexed position for some time before symptoms recur.
Attempting to recreate symptoms by holding the elbow in flexion is demonstrated during the elbow-flexion test described
below.
If Guyons canal syndrome is the problem, pain is common with wrist hyperextension, either actively or passively. In
hyperextension the nerve is pulled taut across the carpal bones, and if damaged from compression, the increased tension
on the nerve will aggravate symptoms.
There are two special orthopedic tests commonly used to help identify ulnar nerve compression. The first is the elbowflexion test. It is primarily used to identify cubital tunnel syndrome.
This test begins with the client in a standing or seated position. With the shoulder laterally rotated, the client brings the
elbow into full flexion while the forearm is supinated and the wrist is hyperextended. This is the position used when
carrying a tray, for example. If the condition is unilateral, it is helpful to have the client adopt the position with both sides at
the same time so a comparison with the unaffected side can be made. Cubital tunnel syndrome is probable if symptoms
are reproduced within about 60 seconds while holding this position.

Another test commonly used to evaluate both conditions is Froment's sign. It evaluates weakness of the adductor pollices
that may result from nerve compression. While it doesn't discriminate between these two conditions, it is helpful in
clarifying ulnar nerve involvement in upper-extremity neurological disorders.
In Froment's sign the client holds a piece of paper between the thumb and MCP joint of the index finger. It is best if the
paper is folded several times so it does not tear easily. The practitioner attempts to pull the paper out of the client's grasp.
If the client is able to hold it firmly and the practitioner has a difficult time pulling it from the client's grasp, there is no
perceivable weakness in the adductor pollex muscle. If, however, the client is unable to prevent the practitioner from
easily pulling the paper out (especially compared to the unaffected side), there is a good chance that motor impairment of
the adductor pollex exists.
Traditional methods of treatment
Medical treatment of both conditions emphasizes conservative approaches, such as rest from offending activities and
splints to reduce aggravation of the nerve. Splints are especially helpful at night when the wrist or elbow may be held in
detrimental positions (wrist hyperextension or elbow flexion) for long periods. Once irritation of the nerve is removed it will
usually heal on its own, although the healing process may be slow.
Because Guyons canal syndrome is caused by external compression, removal of the compression is usually sufficient to
treat the problem, although healing may be slow. In cubital tunnel syndrome surgery may be used if conservative
treatment is ineffective. One of the more common surgical procedures is called an anterior transposition. It involves
repositioning the ulnar nerve so it is not compressed in the cubital tunnel. Other procedures include removing a portion of
the medial epicondyle and slicing the aponeurosis that covers the tunnel to make more room for the nerve.
Massage techniques
Massage approaches for these two problems differ due to the nature of the pathology. For example, because Guyons
canal syndrome results from external forces causing compression on the nerve in the tunnel, massage strategies need to
focus on relief of compressive force. The practitioner should avoid any techniques that cause further nerve compression,
evident by an immediate increase in symptoms. Massage performed directly over the irritated nerve in the canal may
actually aggravate the symptoms and impair the healing process.
Cubital tunnel syndrome, on the other hand, is a condition where
compression occurs from muscles, so massage is beneficial. Because
the flexor carpi ulnaris is the primary problem, techniques that reduce
tension in the flexor muscles of the forearm are most important. In
particular, compression broadening (see left figure) and deep
longitudinal stripping (see right figure) will help reduce tension in the
flexor carpi ulnaris and may help mobilize the ulnar nerve within the
cubital tunnel. Caution should be used when performing any massage
techniques over the tunnel so that further compression of the ulnar nerve does not occur.
Stretching (mobilizing) the ulnar nerve through the cubital tunnel is important because lack of
neural mobility may be a primary cause of symptoms. Neural mobilization procedures are
performed by taking the nerve to a stretch position just where pain and discomfort are felt (see
Figure 3). Once that point is reached the nerve is immediately returned to a neutral position.
The stretch position is not held for as long a period as when addressing muscles. The sequence
of stretching and relaxing the nerve is repeated several times to increase neural mobility and
decrease pathological compression.