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| <div class="noeditbox">Welcome to [[ Vrije Universiteit Brussel Evidence- based Practice Project| Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> | | <div class="noeditbox">Welcome to [[ Texas_State_University_Evidence- based_Practice_Project| Texas State University's Evidence-based Practice project space]]. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> |
| '''Original Editor '''- [[User:Adam West|Adam West]], [[User:Fitim Camaj|Fitim Camaj]] | | '''Original Editors ''' |
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| '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] | | '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] |
| </div> | | </div> |
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| == Search Strategy == | | == Search Strategy == |
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| == Definition/Description == | | == Definition/Description == |
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| Cubital tunnel syndrome is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow.
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| == Clinically Relevant Anatomy ==
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| The ulnar nerve is comprised of nerve roots C8 and T1. The ulnar nerve can become compressed withiin the cubital tunnel at multiple levels including: the arcade of Struthers, the medial intermuscular septum, the medial epicondyle, Osborn's ligament at the cubital tunnel and the flexor-pronator aponeurosis.<ref name="Husain">Husain SN, Kaufmann RA. The diagnosis and treatment of cubital tunnel syndrome. Current Orthopaedic Practice: 2008;19(5):470-474.</ref><br>
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| == Epidemiology /Etiology == | | == Epidemiology /Etiology == |
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| Cubital tunnel syndrome may be a result of direct or indirect trauma and is bulnerable to traction, friction, and compression. Traction injuries may be the result of longstanding valgus deformity and flexion contractures, but are most common in throwers due to extreme valgus stress placed on the arm. <ref name="Lee">Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Coin North Am. 1999;30:81-89.</ref> Compression of the nerve at the cubital tunnel may occur due to reactive changes at the MCL, adhesions within the tunnel, hypertrophy of the surrounding musculature, or joint changes.<ref name="Aldridge">Aldridge JW, Bruno RJ, Strauch RJ, Rosenwasser MP. Nerve entrapment in athletes. Clin Sports Med. 2001;20:95-122.</ref><br>
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| == Characteristics/Clinical Presentation == | | == Characteristics/Clinical Presentation == |
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| Early in the disorder, primary complaint is typically medial elbow pain. Numbness and tingling may also be present in the 4th and 5th digits. The patient may also report non-painful "snapping" or "popping" during active and passive flexion and extension of the elbow. A Wartenberg sign (abduction of the fifth digit due to weakness of the third palmar interosseous muscle) may be present. Active and passive ROM may not be decreased. The ulnar nerve may be enlarged or palpable and tender in the groove.<ref name="Sebelski">Sebelski CA. Current concepts of orthopaedic physical therapy. The Elbow: physical therapy management utilizing current evidence.</ref><br>
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| == Diagnostic Procedures ==
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| add text here related to medical diagnostic procedures
| | == Differential Diagnosis == |
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| == Outcome Measures ==
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| McGowan Score, Louisiana State University Medical Center Score, Bishop Score, and Medical Research Council grade, and Northwick Park Questionnaire are a few outcome measures that have been used.<ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliamen L, Schubert W. Anterior transpositin compared with simple decompressin for treatment of cubital tunnel syndrome. J Bone Joint Surg Am. 2007;89:2591-8.</ref>
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| == Examination == | | == Examination == |
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| add text here related to physical examination and assessment<br> | | add text here <br> |
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| <u>The Elbow Flexion Test</u>: Typically performed bilaterally with the shoulder in full external rotation and te elbow actively held in maximal flexion with wrist extension for 1 minute. A positive test is reproduction of numbness and tingling in the ulnar distribution on the involved side. Specificity (0.99) Sensitivity (0.75).<ref name="Behr">Behr CT, Altchek DW. The elbow. Clin Sports Med. 1997;16:681-704.</ref><br>
| | == Medical Management (current best evidence) == |
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| <u>The Pressure Provocative Test</u>: The clinician applies pressure at the ulnar nerve at the cubital tunnel with the UE positioned as in the elbow flexion test for 30 seconds. Sensitivity (0.91).<ref name="Novak and Lee">Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. j Hand Surg Am. 1994;19:817-820.</ref> | | add text here <br> |
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| <u>Tinel Sign</u>: Reproduction of tingling and numbness into the 4th and 5th digits with tapping of the ulnar nerve at the cubital tunnel. Specificity (0.98) Sensitivity (0.70).<ref name="Novak and Lee" />
| | == Physical Therapy Management (current best evidence) == |
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| == Medical Management <br> ==
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| <u>Operative Management</u>: Indications for surgical intervention include failure of conservative treatment and an electrodiagnostic test of less than 39 meters per second across the elbow.<ref name="Novak and Lee" /> Several surgical techniques have been advocated for cubital tunnel syndrome. Techniques include: simple decompression, submuscular anterior transposition, and subcuatneous anterior ulnar transposition. Results found no difference in motor nerve-conduction velocityies or clinical outcome scores between simple decompression and ulnar nerve transposition. <ref name="Zlowodzki">Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. J Bone Joint Surg Am. 2007;89:2591-8.</ref>
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| == Physical Therapy Management <br> ==
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| <u>Nonoperative Management</u>: Nonoperative management has been shown to have at least a 50% success rate with low-stage ulnar irritation. Nonoperative management may include a 4-6 week period of immoblization with the elbow splinted at 45 degrees flexion and full supination. It has been recommended that athletes have active rest from sports. Modalities may be used to treat inflammation. Return to throwing is allowed at 4-6 weeks following absence of symptoms with any daily activities or exercise and return to full ROM and strength.<ref name="Sebelski" />
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| There is some low level evidence (case report) that has utilized nerve-gliding techniques, segmental joint manipulation and a home program consisting of nerve gliding and light free weight exercises and was able to achieve positive outcomes.<ref name="Coppieters">Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating nerve-gliding techniques in the copnservative treatment of cubital tunnel syndrome. J Manipulative Physiol Ther 2004;27:560-568.</ref>
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| == Differential Diagnosis<br> ==
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| Differential diagnosis should include cervical radiculopathy, thoracici outlet syndrome, MCL insufficiency, tophaceous gout, and calcium pyrophosphate dehydrate crystal deposition.<ref name="Sebelski" /><br>
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| == Key Research == | | == Key Research == |
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| add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> | | add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> |
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| Zlowodzki and Chan<ref name="Zlowodzki" />
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| Meta-Analysis of four RCT comparing simple decompression with anterior ulnar nerve transpostions. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% CI = -0.36 to 0.28], p = 0.81. Authors did not find significant heterogeneity across the studies. Two reports presented postoperative motor nerve conduction vlocities; they showed no significant difference between the the procedures. Conclusion: Data suggests that simple decompression is a reasonable alternative to anterior transposition for surgical management of ulnar nerve compression at the elbow.
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| == Resources <br> == | | == Resources <br> == |
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| add appropriate resources here <br> | | add appropriate resources here <br> |
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| == Case Report ==
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| Coppieters and Bartholomeeusen<ref name="Coppieters" />
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| The objective was to discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The patient was a 17 year old female with traumatic onset of cubital tunnel syndrome. She had pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were presentwhich were regarded as contributing factors hindering natural recovery. Six treatments included nerve-gliding techniques, segmental joint manipulation, and a home program of nerve gliding and light free-weight exercises. Substantial improvement was recorded on both the impairment and functional level. Symptoms did not recur within 10-month follow-up period. Pain and disability had completely resolved.
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| == Clinical Bottom Line == | | == Clinical Bottom Line == |
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == |
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| | see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] |
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| <rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1tUjNYI-_9Js-9CLZ61f-RfYmnSd5DpJiCYwauPMSVUmHW1ga8|charset=UTF-8|short|max=10</rss> | | <rss>Feed goes here!!|charset=UTF-8|short|max=10</rss> |
| </div> | | </div> |
| == References == | | == References == |
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| References will automatically be added here, see [[Adding References|adding references tutorial]].
| | see [[Adding References|adding references tutorial]]. |
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| <references /> | | <references /> |
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| [[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Articles]] [[Category:Condition]] [[Category:Elbow]] [[Category:EIM_Student_Project_2]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Neurodynamics]] | | [[Category:Texas_State_University_EBP_Project|Template:TXSTEBP]] |
