Management of Ulnohumeral Arthritis with Concurrent Cubital Tunnel Syndrome
For patients with ulnohumeral arthritis and cubital tunnel syndrome, initiate conservative management with NSAIDs, physical therapy, and elbow splinting first, but proceed directly to surgical intervention—combining arthroscopic debridement with osteophyte removal and ulnar nerve decompression—if conservative treatment fails within 3 months or if motor weakness, muscle atrophy, or fixed sensory changes are present at initial evaluation. 1, 2
Initial Assessment and Diagnosis
Critical Clinical Features to Identify
- Ulnar nerve symptoms: Numbness and tingling in the ring and small fingers (earliest sign), hand clumsiness, weakness of grip strength, and atrophy of the first dorsal interosseous muscle 3
- Arthritis manifestations: Medial elbow pain, restricted range of motion, joint stiffness, and palpable osteophytes 4, 2
- Physical examination findings: Positive Tinel's sign at the cubital tunnel, positive flexion-compression test, palpable thickening of the ulnar nerve, and point tenderness at the medial epicondyle 3, 1
Diagnostic Imaging Protocol
- Radiographs (AP, lateral, and oblique views): Essential first-line imaging to identify osteophytes in the humeroulnar joint, loose bodies, joint space narrowing, and heterotopic ossification 4, 2
- MRI of the elbow: Indicated when radiographs are normal or nonspecific to visualize osteochondral lesions, soft tissue compression of the ulnar nerve, and occult ganglion cysts 4, 5
- Nerve conduction studies: Confirm ulnar nerve compression and establish baseline severity 3, 1
- Ultrasound: Useful adjunct to demonstrate morphological changes in the nerve and identify space-occupying lesions like small ganglion cysts 1, 5
Conservative Management (First-Line for Mild-Moderate Cases)
Arthritis-Directed Treatment
- Topical NSAIDs (diclofenac 2%): Apply twice daily as first-line pharmacologic treatment with lower systemic exposure 4, 6
- Oral NSAIDs: Use at the lowest effective dose for the shortest duration, considering cardiovascular and gastrointestinal risks 4, 6
- Supervised exercise program: Strengthening and low-impact aerobic exercises for at least 30 minutes most days, adapted to functional capacity 4, 6
- Activity modification: Avoid repetitive elbow flexion, prolonged pressure on the medial elbow, and activities that exacerbate symptoms 3, 1
Nerve-Directed Treatment
- Elbow splinting: Night splints maintaining the elbow in 30-45 degrees of flexion to minimize nerve stretching 3, 1
- Nerve gliding exercises: Gentle ulnar nerve mobilization exercises to reduce adhesions 3
- Avoid external pressure: Eliminate leaning on elbows, prolonged phone use with elbow flexion, and activities requiring sustained elbow flexion 1, 5
Duration and Reassessment
- Reassess at 4-6 weeks: Evaluate response to topical NSAIDs and physical therapy 6
- Maximum conservative trial: 3 months before proceeding to surgical intervention if symptoms persist or worsen 1
Surgical Intervention (Definitive Treatment)
Indications for Surgery
Proceed directly to surgery if any of the following are present:
- Motor weakness or muscle atrophy at presentation 1
- Fixed sensory changes (constant numbness rather than intermittent) 1
- Failure of conservative treatment after 3 months 1
- Severe restriction of elbow range of motion with bone-on-bone contact 2
- Progressive neurologic deterioration despite conservative measures 3, 1
Surgical Technique
The primary cause of cubital tunnel syndrome in the setting of elbow osteoarthritis is degenerative osteophytes in the humeroulnar joint underneath the ulnar nerve. 2
Recommended Surgical Approach
In situ ulnar nerve decompression: Extend decompression at least 5-6 cm distal to the medial epicondyle by cutting all soft tissues covering the nerve (cubital tunnel retinaculum, humeroulnar arcade, and deep flexor/pronator aponeurosis) 1, 2
Osteophyte removal: Remove degenerative osteophytes in the humeroulnar joint underneath the nerve using arthroscopic or open technique 2
Loose body removal: Extract loose bodies from anterior and posterior joint compartments to improve range of motion 2
Internal neurolysis: Perform with microscopy only in cases where nerve constriction is severe 2
Consider anterior transposition: Reserve for cases with severe bone deformity (cubitus valgus), painful ulnar nerve subluxation, or extensive scarring; submuscular transposition provides healthy vascular bed in revision cases 1
Expected Outcomes
- Recovery rate: 75 of 77 cases (97%) achieved recovery of ulnar nerve palsy and improved joint range of motion with combined osteophyte removal and nerve decompression 2
Critical Pitfalls to Avoid
- Delaying surgical intervention: Chronic ulnar nerve compression leads to irreversible muscle atrophy and permanent functional impairment affecting fine motor activities 3
- Incomplete decompression: Failure to extend decompression at least 5-6 cm distal to the medial epicondyle results in persistent compression 1
- Overlooking osteophytes: Missing degenerative osteophytes underneath the nerve—the primary pathology in arthritis-related cubital tunnel syndrome—leads to treatment failure 2
- Inadequate nerve mobilization during transposition: Insufficient proximal or distal mobilization causes nerve kinking and compromised blood flow, necessitating revision surgery 1
- Treating only the nerve without addressing arthritis: Isolated nerve decompression without osteophyte removal fails to address the underlying mechanical compression 2
- Relying solely on conservative treatment in advanced cases: Patients presenting with motor weakness or muscle atrophy require immediate surgical referral, as conservative treatment will not reverse these changes 1
Special Considerations
For Patients with Occult Ganglion Cysts
- Small ganglion cysts originating from the ulnohumeral joint can cause cubital tunnel syndrome, particularly in patients with repetitive elbow flexion (e.g., prolonged motorbike riding) 5
- Surgical resection of the ganglion combined with ulnar nerve decompression is required 5