Treatment of Cubital Tunnel Syndrome & other Forearm and Elbow Conditions

Often secondary to rotator cuff instability, biceps tendonitis occurs when the tendons attaching the biceps muscle to the shoulder and lower arm bone become overused or stressed. The corresponding irritation and inflammation results in tendonitis.

The biceps tendon is vulnerable to such conditions, because it helps control lower arm movement and is subjected to extreme force in such throwing sports as competitive baseball or football.

Symptoms associated with biceps tendonitis include, pain along the front of the shoulder during arm and shoulder movement - particularly forward and upward movements - which intensifies at night and becomes increasingly prevalent during daily activity.

Risk Factors
Those most often affected by biceps tendonitis are competitive athletes involved in throwing positions in a sport. It equally impacts active men and women, who repeatedly subject their arm to such force. Though less common, a direct trauma or calcification in the tendon may also prompt the condition.

Treatment
Following a thorough examination and assessment of the patient’s history and lifestyle, radiographic testing may be indicated in order to determine the severity of the problem and select the best treatment option.

Conservative treatment has proven effective in the treatment of biceps tendonitis and generally involves anti-inflammatory medication and cold compression. A rehabilitative exercise program designed to strengthen and promote flexibility and balanced conditioning of opposing muscles is established. Corticosteroid injections may also be indicated in order to reduce the inflammation and pain.

While the exact cause of Cubital Tunnel Syndrome is unclear, it is recognized as the most common form of entrapment of the ulnar nerve and the second most common nerve compression syndrome of the upper extremity. It is believed that when the ulnar nerve, which stretches when the elbow is bent or sustains pressure, sometimes shifts over the bony medial epicondyle on the inside edge of the elbow and causes irritation.

The ulnar nerve is mainly a motor and sensory nerve for the hand, supplying the flexor carpi ulnaris (FCU) muscle and the ring and small flexor digitorum profundus (FDP) muscles in the elbow and forearm region. It may also become irritated when subjected to long periods of pressure such as that produced when leaning against a hard service. Irritation can also occur if it becomes damaged as a result of force placed on the cubital tunnel.

The symptoms are similar to those experienced with other elbow conditions, such as medial epicondylitis or "golfer's elbow" - the sharp pain experienced when the "funny bone" is hit. The "funny bone" is actually the prominent bony portion of the elbow over which the ulnar nerve runs. Common symptoms more distinctly related to cubital tunnel syndrome include, numbing in the hand and/or ring and little fingers, general pain and muscle weakness in the hand and thumb affecting grip strength and the ability to perform certain activities.

Risk Factors
This type of ulnar entrapment neuropathy develops as a result of the anatomy of the elbow and biomechanics of the ulnar nerve at the elbow, which creates an environment predisposed to compression. Those most likely to experience cubital tunnel syndrome are adults working for long periods at a desk, as well as competitive athletes and workers involved in manual labor and accident resulting in trauma to the elbow. Occasionally, overzealously pursuing a weekend project that places uncommon stress and pressure on the elbow can also prompt the condition.

Treatment
Following a thorough examination and assessment of patient history and lifestyle, an elbow flexion test and nerve conduction test may be indicated, in order to assess pain relative to position and signal speed traveling down the nerve. This will help indicate whether the nerve is compressed and to what degree. Before treatment is determined, an electromyogram (EMG) focusing on the forearm muscle may be used in order to evaluate nerve and muscle function. Poor muscle function may also indicate a problem with the ulnar nerve.

Most cases of cubital tunnel syndrome can be treated conservatively and may entail a period of rest from the activity causing the irritation, splinting and anti-inflammatory medication. A rehabilitation program may also be indicated, in order to help modify the movement responsible for the initial irritation. For those nonresponsive to conservative treatment, surgical decompression or transposition procedure may be necessary to relieve pain and restore function. The symptoms and severity of the condition will determine the best course of action.

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Medial epicondylitis, or Golfer's Elbow, affects the opposite side of the elbow as lateral epidondylitis, or Tennis Elbow. Therefore it is easy to differentiate between the two based on the location of the pain - medial identifies the inside portion of the elbow and lateral the outer portion.

While the condition is referred to as Golfer’s Elbow, any number of activities subjecting the wrist and elbow to constant and excessive force, causing damage to the tendons responsible for bending the elbow, can result in medial epicondylitis - including pitching, chopping wood, serving a tennis ball or swinging a golf club.

The symptom most commonly associated with the condition is pain that generates from the elbow to the wrist - along the palmar side of the forearm.

Risk Factors
Both athletes and average adults who apply repeated bending force to the wrist and elbow are likely to experience medial epicondylitis. It is most often seen in individuals between the ages of 20 and 40, who are involved in certain sports or forceful manual labor activities.

Treatment
A physical examination and review of the patient's history and lifestyle help determine diagnosis and the best form of treatment. While most often treated with conservative treatment, which may entail cold compression, anti-inflammatory medications, and rehabilitative exercises, surgical repair may be necessary in cases of more severe ligament damage.

Radial Tunnel Syndrome is a nerve condition resultant of a repetitive stress that causes irritation and compression on the radial nerve.

The radial nerve plays a large role in the function of several muscles around the wrist and hand, which, when compressed or pinched at the forearm or elbow, cause the affected muscles to become weak.

This type of nerve compression can also result from an injury and surface as a ganglia, lipoma, bone tumor and inflammation of the surrounding bursa or muscles. Associated symptoms are similar to those experienced with Tennis Elbow (lateral epicondylitis) and include pain at the top of the forearm and back of the hand when the wrist and fingers are straightened out. The symptom similarities are the only things these two conditions share.

Since the radial nerve primarily connects to muscle, there is no loss of sensation. The radial nerve begins at the side of the neck, where individual nerve roots leave the spine. The nerve roots exit through small openings (called foramen) between the vertebrae. The nerve roots join to form the three main nerves responsible for arm and hand function (radial, ulnar and median) - and travel down the arm to the hand. The radial nerve passes down the back of the upper arm, around the outside of the lateral portion of the elbow and down the forearm and hand.

Risk Factors
Radial tunnel syndrome most often affects athletes and individuals involved in activities requiring repetitive, forceful movements of the arm - such as pushing, pulling, gripping, bending and twisting on a regular basis. While the condition is most often classified as a repetitive stress condition, it can occasionally also result from a single direct blow to the outside of the elbow.

Treatment
A thorough examination and assessment of the patient's history and lifestyle is necessary in identifying and properly treating radial tunnel syndrome. An electromyogram (EMG) can help muscle function, and a nerve conduction velocity (NCV) test can help determine if nerve compression exist.

Treatment options for nerve compression conditions are generally conservative and may consist of a period of rest from the activity responsible for the irritation, as well as a removable arm splint and rehabilitative exercises.

More severe cases and those nonresponsive to conservative treatment may require surgical repair. This nerve decompression procedure is performed on an outpatient basis and followed by a rehabilitation program that refines hand and arm positions during certain activities, in order to reduce the likelihood of a recurrence.

Tennis Elbow is an overstress or overuse condition affecting the tendon around the lateral epicondyle, or bony bump, located at the back or outside of the elbow.

Referred to medically as lateral epicondylitis, the condition is the irritation and subsequent inflammation of the tendon resultant of a potentially degenerative environment within the tendon.

Those suffering from Tennis Elbow may experience moderate pain at the outer portion of the elbow that over time increases and spreads down the forearm and to the back of the middle and ring fingers. If left untreated, the pain will eventually become debilitating, causing progressive weakening and reduction in arm function. Reaching and grasping activities may become painful, and persistent discomfort may be present while at rest following activities.

Risk Factors
Though most commonly known as Tennis Elbow, most individuals diagnosed with the condition are not tennis players. Those most affected are average adults between the ages of 40 and 60, who are involved in everyday activities - gardening, picking up children, storing luggage in an overhead compartment, painting with a brush or roller, using a chain saw or hand tools.

Any activity resulting in the overuse of the muscles and tendons of the forearm and elbow is likely to prompt the condition.

Treatment
Following a thorough examination, assessment of the patient's history and lifestyle, and imaging scans, treatment is determined based on the severity of the condition. Generally beginning with conservative treatments that work to prevent further degeneration of the tissue and reduce inflammation, other minimally invasive procedures are indicated if symptoms persist. Other nonsurgical treatments may include ultrasound therapy or electrohydraulic shockwave energy treatment, which is performed as an outpatient procedure in less than 20 minutes.

Chronic conditions failing to respond to nonsurgical treatment may require a lateral epicondyle release, which is also performed as an outpatient procedure.

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