Initial Management of Ulnar Nerve Infringement
Conservative treatment should be tried first for mild to moderate cases of ulnar neuropathy, with patient education and activity modification as the initial management approach. 1
Diagnostic Considerations
When evaluating ulnar nerve infringement, consider:
- Distinguishing ulnar neuropathy from other causes such as cervical radiculopathy, thoracic outlet syndrome, vitamin B12 deficiency, hypothyroidism, and alcohol toxicity 1
- Location of symptoms (typically diminished sensation or dysesthesias in the fourth or fifth digits, often with pain in the proximal medial aspect of the elbow) 2
- Severity of symptoms (mild, moderate, or severe)
Initial Conservative Management
1. Patient Education and Activity Modification
- Educate patients on avoiding prolonged elbow flexion and direct pressure on the nerve 1
- Encourage optimal postural alignment at rest and during activities 1
- Provide information on avoiding movements or positions that exacerbate symptoms 3
2. Splinting
- Apply elbow splinting for acute and subacute neuropathy 4
- Splint devices have shown improvement of symptoms in 89% of cases (95% CI, 69-99) 5
- Night splinting may be beneficial to prevent prolonged elbow flexion during sleep 3
3. Pharmacological Management
For patients with neuropathic pain, consider:
First-line medications:
Topical agents:
Caution: Avoid tricyclic antidepressant dosages higher than 100 mg/day due to increased risk of cardiac events 1
4. Injection Therapy
- Steroid/lidocaine injections have shown improvement in 54% of cases (95% CI, 41-67) 5
- However, evidence suggests no significant difference versus placebo in improving symptoms at three months' follow-up 3
Imaging Considerations
If conservative management fails or diagnosis is uncertain:
- MRI is the reference standard for imaging ulnar nerve entrapment, with T2-weighted MR neurography showing high signal intensity and nerve enlargement 1
- Ultrasound assessment of cross-sectional area/nerve thickness has high accuracy rates, with dynamic ultrasound helpful in demonstrating nerve dislocation 1
When to Consider Surgical Referral
Consider surgical referral in the following circumstances:
- Severe symptoms unresponsive to conservative measures 1
- Progressive neurological deficits 1
- Failed conservative treatment after approximately 3 months 1
- Significant functional limitation 1
- Habitual ulnar nerve subluxation/dislocation at the elbow 1
- Complete nerve rupture requiring surgical evaluation 1
Follow-up and Monitoring
- Regular reassessment of pain and function is necessary 1
- Monitor for medication side effects, especially with tricyclic antidepressants (anticholinergic effects, cardiac toxicity) 1
- Adjust treatment based on response 1
- Consider referral to physical therapy if symptoms persist 1
Common Pitfalls to Avoid
- Failing to protect pressure points during surgery or procedures (ulnar nerve is at risk when supine) 6
- Overlooking the possibility of nerve dislocation (dynamic ultrasound can help identify this) 1
- Delaying surgical referral when conservative management fails after 3 months 1
- Using only clinical tests to assess recovery (these have low sensitivity) 6
- Neglecting to distinguish ulnar neuropathy from other conditions with similar presentations 1
Based on the available evidence, splinting appears to be preferred over injections as it shows a higher rate of improvement 5, but a comprehensive approach including patient education, activity modification, and appropriate pharmacological management offers the best chance for symptom improvement in mild to moderate cases.