What are the treatment options for a patient with ulnar nerve impingement?

Treatment of Ulnar Nerve Impingement

Begin with conservative management including activity modification, neutral elbow positioning, padding protection, and paracetamol for pain control; reserve surgical decompression for patients with progressive motor weakness, persistent symptoms despite 3-6 months of conservative care, or severe (McGowan Grade 3) disease. 1, 2, 3

Initial Diagnostic Workup

• Obtain plain radiographs first to exclude osseous abnormalities, fractures, or arthritis that may contribute to nerve compression 4
• Perform electrodiagnostic studies (nerve conduction studies and EMG) to confirm the diagnosis, localize the site of compression, differentiate demyelinating from axonal injury, and establish baseline severity 2, 5
• Order MRI without IV contrast if diagnosis remains unclear or to evaluate for space-occupying lesions, with T2-weighted neurography showing high signal intensity and nerve enlargement at the compression site 2, 5
• Consider ultrasound as an alternative imaging modality with high diagnostic accuracy (sensitivity 77-79%, specificity 94-98%) for assessing nerve cross-sectional area and thickness 2, 5

Conservative Management (First-Line Treatment)

Positioning and Activity Modification

• Maintain neutral forearm position when the arm is at the side to minimize nerve tension 2, 5
• Limit elbow flexion to less than 90° as excessive flexion increases pressure in the cubital tunnel and exacerbates symptoms 2, 5
• Avoid prolonged pressure on the postcondylar groove (ulnar groove at the elbow) during daily activities and sleep 2, 5
• Limit arm abduction to 90° in supine positions to prevent additional nerve stretch 2, 5

Protective Padding

• Apply foam or gel padding at the elbow to prevent direct compression, ensuring padding is not too tight as this can create a tourniquet effect and worsen symptoms 2

Pharmacologic Pain Management

• Start with paracetamol up to 4g daily as first-line oral analgesic due to its favorable efficacy and safety profile 1, 2, 5
• Use topical NSAIDs for localized pain to minimize systemic side effects 1, 2, 5
• Add oral NSAIDs at the lowest effective dose for the shortest duration only if paracetamol provides inadequate relief 1, 5

Physical Therapy

• Prescribe range of motion and strengthening exercises to maintain elbow and wrist function 1, 2, 5
• Apply local heat before exercise to enhance tissue flexibility and reduce discomfort 1, 5

Duration of Conservative Trial

• Continue conservative management for 3-6 months before considering surgical intervention, unless there is progressive motor weakness 3, 6

Surgical Management (When Conservative Treatment Fails)

Indications for Surgery

• Progressive motor weakness or muscle atrophy (intrinsic hand muscle weakness) 3
• Persistent sensory symptoms despite 3-6 months of conservative care 3
• Severe preoperative status (McGowan Grade 3) with significant functional impairment 6

Surgical Options Based on Evidence

For patients without nerve subluxation:

• Perform simple decompression in situ as the primary surgical approach, which has the best overall outcomes across all preoperative grades, preserves nerve vascularity, and allows rapid rehabilitation 6
• Consider subtotal medial epicondylectomy as an alternative that allows decompression at all levels with minimal risk of devascularization or elbow instability 7

For patients with intraoperative nerve subluxation:

• Perform anterior intramuscular transposition which shows the best outcomes for severe (McGowan Grade 3) cases when subluxation is present 6

Avoid as first-line:

• Anterior subcutaneous and submuscular transposition have shown the worst outcomes in literature analysis 6

Surgical Pitfalls

• Avoid extensive internal neurolysis as secondary procedures, which have poor pain outcomes (only 1 of 6 patients pain-free) 8
• Be aware that 58% of patients experience postoperative pain, with severe radiating pain being the main indication for revision surgery 8
• If revision is needed for intractable pain after transposition, consider transferring the nerve back into the sulcus, which achieved pain-free status in all 5 patients in one series 8

Monitoring and Follow-Up

• Reassess at 4-6 week intervals during conservative management to monitor for progression of motor weakness 3
• Repeat electrodiagnostic studies if symptoms worsen to assess for progression from demyelinating to axonal injury 5
• Continue long-term follow-up after surgery as outcomes vary and some patients may develop chronic postoperative pain requiring additional intervention 8