Cubital Tunnel Syndrome

• Numbness and tingling in the ring and small fingers — the hallmark symptom, often worse at night or when the elbow is flexed
• Aching medial elbow pain radiating down the forearm
• Intrinsic muscle weakness: difficulty spreading the fingers, weakened grip, trouble with fine motor tasks (buttoning, typing)
• Wartenberg sign: persistent abduction of the small finger due to weakness of the interosseous muscles relative to the extensor digiti minimi
• Froment sign: flexion of the interphalangeal joint of the thumb when pinching paper, indicating adductor pollicis weakness (anterior interosseous nerve-independent adduction is lost)
• In advanced cases: visible wasting of the intrinsic muscles (hypothenar and interosseous atrophy), permanent clawing of the ring and small fingers

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

Physical Examination

• Elbow Flexion Test: The patient fully flexes the elbow and extends the wrist for 60 seconds. Reproduction of tingling in the ring/small fingers is a positive test (sensitivity ~75%).
• Tinel sign at the cubital tunnel: Tapping over the ulnar nerve at the medial elbow produces distal paresthesia.
• Wartenberg and Froment signs (see above) indicate motor involvement.
• Nerve palpation may reveal subluxation of the ulnar nerve anterior to the medial epicondyle with elbow flexion.

Electrodiagnostic Studies

Nerve conduction studies (NCS) and electromyography (EMG) remain the objective gold standard for confirming ulnar nerve entrapment at the elbow, quantifying severity, and ruling out proximal (cervical) or distal (Guyon's canal) pathology. Slowing of ulnar motor conduction velocity across the elbow segment below 50 m/s is diagnostic. EMG documents denervation changes in ulnar-innervated intrinsic muscles.

Imaging

Plain radiographs assess for medial epicondyle osteophytes, heterotopic ossification, or valgus deformity. MRI or ultrasound can identify nerve edema, subluxation, and structural causes of compression (ganglia, anomalous muscle).

• Conservative management: Symptoms often improve within 4–8 weeks of consistent splinting and activity modification.
• In-situ decompression: Sling for 1–2 weeks; PT for ROM and nerve gliding; return to work at 2–4 weeks; full recovery at 6–12 weeks.
• Anterior transposition: Splint/cast for 2–3 weeks; formal PT for 6–8 weeks; return to overhead sport at 3–4 months; nerve recovery continues for up to 12–18 months depending on pre-operative severity.

Complete motor recovery is more likely when surgery is performed before the development of fixed intrinsic atrophy or clawing. Early referral is strongly encouraged for patients with motor weakness.