What are the treatment options for ulnar neuropathy?

Treatment of Ulnar Neuropathy

The treatment of ulnar neuropathy should begin with conservative management, including patient education on proper positioning, activity modification, and pharmacological therapy, with surgical intervention reserved for cases that fail to respond to conservative measures or show progressive neurological deficits. 1

Conservative Management

Patient Education and Activity Modification

• Avoid prolonged elbow flexion and maintain neutral forearm position 1
• Limit arm abduction to 90° when in supine position 2
• Avoid positions that place pressure on the ulnar groove 1
• Maintain optimal postural alignment to reduce symptoms 1

Adjunctive Therapies

• Night splinting
• Nerve gliding exercises
• Heat application 1
• Information on avoiding prolonged movements or positions has been shown to be effective in improving subjective discomfort in mild to moderate cases 3

Pharmacological Management

• First-line medications:
  • Calcium channel α2-δ ligands: gabapentin (900-3600 mg/day) or pregabalin (300-600 mg/day)
  • Tricyclic antidepressants: nortriptyline or desipramine (start at 10 mg/day, titrate up to 75 mg/day)
  • SNRIs: duloxetine (60-120 mg/day) or venlafaxine (150-225 mg/day) 1
  • Avoid tricyclic antidepressant dosages higher than 100 mg/day due to increased risk of cardiac events 1
• Topical agents: lidocaine patches or creams for localized neuropathic pain 1
• Corticosteroid injection has not shown significant benefit over placebo in improving symptoms at three months 3

Surgical Management

Indications for Surgery

• Failure of conservative treatment after approximately 3 months
• Progressive neurological deficits
• Severe symptoms with significant functional limitation
• Habitual ulnar nerve subluxation/dislocation at the elbow 1

Surgical Options

1. Simple decompression - Moderate-quality evidence shows this is equally effective as transposition procedures with fewer wound infections 3
2. Decompression with transposition:
   • Subcutaneous transposition
   • Submuscular transposition
   • Intramuscular transposition 4
3. Medial epicondylectomy - No difference in outcomes compared to anterior transposition 3
4. Endoscopic decompression - Similar clinical outcomes to open decompression but higher risk of hematoma 3

Treatment Algorithm Based on Etiology

1. For entrapment under the humeroulnar aponeurosis (HUA):

   • Surgical release is recommended 5

2. For extrinsic compression in the retrocondylar (RTC) groove:

   • Conservative management with avoidance of inappropriate arm positioning 5

Monitoring and Follow-up

• Regular reassessment of pain and function
• Monitor for medication side effects, especially with tricyclic antidepressants (anticholinergic effects, cardiac toxicity)
• Consider referral to physical therapy if symptoms persist 1
• Optimize glucose control in patients with diabetes to prevent progression of ulnar neuropathy 1

Pitfalls and Caveats

• Distinguish ulnar neuropathy from other causes such as cervical radiculopathy, thoracic outlet syndrome, vitamin B12 deficiency, hypothyroidism, and alcohol toxicity 1
• Outcomes for revision surgery are generally less favorable than primary procedures 4
• Risk factors for ulnar nerve injury include body habitus, pre-existing neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and arthritis 1
• During any surgical procedure, protect pressure points to prevent iatrogenic ulnar nerve injury, especially when the patient is supine 1

Diagnostic Considerations

• MRI is the reference standard for imaging ulnar nerve entrapment 1
• Ultrasound assessment of cross-sectional area/nerve thickness has high accuracy rates for ulnar nerve entrapment evaluation 1
• Using only clinical tests to assess recovery has low sensitivity 1