What is the treatment for cubital tunnel syndrome?

Treatment of Cubital Tunnel Syndrome

For mild to moderate cubital tunnel syndrome, begin with conservative management using rigid night splinting (maintaining 45° of elbow flexion) combined with activity modification for 3 months, which successfully avoids surgery in approximately 88% of patients. 1

Initial Conservative Management

First-Line Treatment Approach

• Initiate rigid night splinting maintaining the elbow at 45° of flexion combined with activity modification as the primary treatment for mild to moderate symptoms, with treatment duration of 3 months. 1
• Educate patients to avoid prolonged elbow flexion, direct pressure on the medial elbow, and repetitive elbow flexion activities during daily activities. 2
• Both education/activity modification alone and splinting appear equally effective based on moderate-strength evidence, so either approach is reasonable. 2

Expected Outcomes with Conservative Treatment

• Approximately 88% of patients with mild to moderate cubital tunnel syndrome avoid surgical intervention with this conservative approach. 1
• Significant improvements occur in disability scores (Quick DASH improving from 29 to 11) and quality of life measures (SF-12 physical component improving from 45 to 54). 1
• Grip strength increases significantly (average 32 kg to 35 kg), and ulnar nerve provocative testing resolves in 82% of successfully treated patients. 1
• Patient compliance with rigid night splinting protocols is typically high during the 3-month treatment period. 1

Indications for Surgical Intervention

When to Proceed with Surgery

• Surgical decompression is indicated when conservative treatment fails after 3 months, or when patients present with motor weakness, muscle atrophy, or fixed sensory changes at initial evaluation. 3
• Advanced disease with irreversible muscle atrophy and hand contractures requires surgical intervention to prevent permanent dysfunction. 4, 5

Surgical Technique Selection

• Simple in situ decompression is the treatment of choice for primary cubital tunnel syndrome, extending at least 5-6 cm distal to the medial epicondyle, and can be performed using open or endoscopic techniques under local anesthesia. 3
• Simple decompression is also preferred for uncomplicated ulnar nerve subluxation and most post-traumatic or secondary forms. 3
• Subcutaneous anterior transposition should be considered when ulnar nerve luxation is painful or when the nerve "snaps" back and forth over the medial epicondyle. 3
• Anterior transposition (subcutaneous or submuscular) is indicated in cases of severe bone or tissue changes of the elbow, particularly with cubitus valgus deformity. 3
• Submuscular transposition may be preferred in cases of scarring, as it provides a healthy vascular bed and soft tissue protection for the nerve. 3

Critical Pitfalls to Avoid

Conservative Management Errors

• Avoid proceeding directly to surgery in patients with very mild electrodiagnostic findings without attempting conservative treatment, as 48-63% will respond to conservative measures. 6
• Do not rely on NSAIDs, acetaminophen, or ibuprofen as adequate conservative treatment, as these medications have limited efficacy for nerve compression and do not address the underlying pathology. 6

Surgical Technique Complications

• Ensure adequate proximal and distal mobilization during nerve transposition to prevent kinking of the nerve, which can compromise blood flow and require revision surgery. 3
• Avoid injecting corticosteroids within 3 months of planned surgery if conservative treatment fails, as this increases infection risk. 6
• Recognize that transposition procedures carry risks of compromising blood flow to the nerve compared to simple decompression. 3

Diagnostic Confirmation

Clinical and Electrodiagnostic Assessment

• Clinical diagnosis should be confirmed by nerve conduction studies before initiating treatment. 3
• Ultrasound and MRI have become useful diagnostic tools by showing morphological changes in the nerve within the cubital tunnel. 3
• Consider differential diagnoses in atypical cases, including C8 radiculopathy, Pancoast tumor, and pressure palsy. 3

Treatment Algorithm Summary

1. Mild to moderate symptoms without motor weakness or atrophy: Begin 3-month trial of rigid night splinting (45° elbow flexion) plus activity modification 1
2. Failed conservative treatment after 3 months: Proceed to simple in situ decompression 3
3. Presentation with motor weakness, muscle atrophy, or fixed sensory changes: Proceed directly to surgical decompression 3
4. Painful nerve subluxation or severe elbow deformity: Consider anterior transposition rather than simple decompression 3