Cubital tunnel syndrome
The ulnar nerve is one of the major nerves supplying the arm and hand. It begins from nerves leaving the spinal cord in the neck, passes through the neck and beneath the collarbone, then travels down the inner side of the arm. At the elbow it passes through a relatively confined space behind the medial epicondyle — the bony prominence on the inside of the elbow — before continuing into the forearm and hand. This is the nerve you may recognise from hitting your “funny bone.”
The area behind the elbow is also one of the commonest places for the ulnar nerve to become irritated or compressed. The nerve may become tight as the elbow bends or can be compressed by surrounding fascia and other soft tissues.
Typical symptoms include pins and needles or numbness in the little and ring fingers, although everyone's symptoms do not follow an identical pattern. Keeping the elbow deeply bent can make symptoms worse, which is why people with cubital tunnel syndrome frequently wake during the night with an uncomfortable numb or tingling hand.
If compression becomes more significant or prolonged, the muscles supplied by the nerve can also become affected. You may notice reduced grip strength, difficulty with fine movements or loss of dexterity in the hand.
How is cubital tunnel syndrome investigated and treated?
Nerve conduction studies, often combined with EMG, use electrical stimulation to assess how effectively the nerve is transmitting signals and can help identify where compression is occurring. These tests are useful but are not 100% accurate, and are therefore interpreted alongside your symptoms and examination rather than relied upon alone.
Treatment can initially be very simple. Avoiding prolonged deep elbow flexion — particularly whilst sleeping — and sometimes using a night splint can reduce irritation of the nerve. If symptoms persist, or there is evidence that the nerve is beginning to affect the muscles of the hand, surgery may be appropriate.
A cubital tunnel release is usually a relatively small operation which releases the structures constricting the nerve and allows it to move freely. If the nerve remains stable behind the elbow, this may be all that is required. Occasionally the nerve itself moves or “flicks” around the inside of the elbow. In selected patients it may therefore need to be moved to a more stable position in front of the elbow. This is called an anterior transposition of the ulnar nerve and is a slightly more involved procedure.
Tennis elbow
Despite the name, you absolutely do not need to play tennis to develop tennis elbow. Tennis elbow — or lateral elbow tendinopathy — affects the common origin of the tendons that extend the wrist and fingers, where they attach to the outside of the elbow. It is extremely common and can develop following repetitive gripping, lifting, manual work, gym activity or sometimes for no obvious reason at all.
Pain is usually felt directly over the outside of the elbow and can be particularly noticeable when gripping something, lifting a kettle, opening a jar or carrying a bag with the palm facing down. Although it has traditionally been described as “inflammation”, persistent tennis elbow is better thought of as a tendon problem, with changes occurring within the tendon itself.
Steroid injections can produce impressive short-term pain relief, but the longer-term evidence is much less favourable, and current British Elbow & Shoulder Society (BESS) guidance strongly recommends that corticosteroid injections should not be used to treat lateral elbow tendinopathy. Physiotherapy and progressive loading are the mainstay of treatment.
Golfer's elbow
Golfer's elbow — or medial elbow tendinopathy — is similar to tennis elbow but affects the common flexor tendon origin on the inside of the elbow. Again, you don't need to play golf to develop it. It is considerably less common than tennis elbow and can cause pain with gripping, lifting and resisted wrist flexion.
One important difference is the proximity of the ulnar nerve. The nerve passes immediately behind this part of the elbow, so medial-sided elbow pain needs careful assessment to establish whether symptoms are coming from the tendon, the nerve, or both. If there is associated tingling in the little or ring fingers, altered sensation or weakness in the hand, whether cubital tunnel syndrome is contributing will be considered carefully.
Treatment is usually non-operative, with activity modification and a structured physiotherapy programme concentrating on progressive loading of the flexor-pronator muscles. Surgery is only occasionally necessary. In patients with persistent medial tendinopathy who also have significant ulnar nerve compression, the tendon problem and ulnar nerve can sometimes be addressed during the same operation.
Radial tunnel syndrome
Radial tunnel syndrome is much less common and, partly for that reason, can be difficult to diagnose. A branch of the radial nerve passes through several structures around the outside of the elbow and upper forearm. Compression or irritation in this region can cause aching pain in the outer forearm and may sometimes be mistaken for tennis elbow.
The exact position of the pain and findings on examination help distinguish the two conditions. Nerve conduction studies and EMG may be useful as part of the investigation, although — as with other nerve conditions — they need to be interpreted alongside the clinical picture and can sometimes be normal in radial tunnel syndrome.
If the diagnosis is clear and symptoms remain troublesome despite non-operative treatment, surgical decompression of the radial nerve can be considered. The principle of the operation is relatively straightforward: the structures constricting the nerve are released to give it more room. The important part is therefore making sure we have the correct diagnosis before considering surgery.
Elbow arthritis, stiffness and loose bodies
Arthritis occurs when the smooth cartilage covering the surfaces of a joint becomes damaged or worn. The elbow is different from the hip or knee. Many people with elbow arthritis retain a surprisingly functional arm, but develop pain at the extremes of movement, progressive loss of movement, catching or locking.
Small fragments of bone or cartilage — known as loose bodies — can also develop within an arthritic or previously injured elbow. These can intermittently become trapped in the joint and produce sudden catching or locking. Elbow arthritis can be challenging to treat, and an elbow replacement is very different from a hip or knee replacement.
A total elbow replacement can provide excellent pain relief in carefully selected patients, but it comes with significant lifelong restrictions on how much weight can safely be lifted through the arm. Historically, elbow replacement was particularly associated with severe inflammatory arthritis such as rheumatoid arthritis. Modern medical treatment has fortunately reduced the number of patients reaching this stage, and elbow replacement is now also used selectively for osteoarthritis, post-traumatic arthritis and some complex fractures.
Because elbow replacement is a relatively uncommon and specialist procedure, current UK guidance recommends that this surgery is concentrated within regional specialist elbow-replacement networks, rather than being performed occasionally in many different hospitals. Complex primary and revision procedures may also be undertaken jointly by two specialist consultants. For an active patient who wants to continue lifting and using the arm heavily, replacement may therefore not be the right solution.
Fortunately, there are other options. Depending on the pattern of arthritis and stiffness, treatment may include arthroscopic (keyhole) surgery to remove loose bodies, osteophytes or other mechanical blocks to movement; open arthrolysis, where contracted tissue and bony restrictions around the elbow are released to improve movement; or a column procedure, which can provide access to the joint to remove impinging bone and release stiffness whilst preserving the patient's own elbow. These procedures cannot reverse arthritis, but in appropriately selected patients they can improve movement, reduce mechanical symptoms and sometimes improve pain while preserving the natural joint.
Elbow ligament injuries and instability
The elbow is stabilised not only by its bony shape but by strong ligament complexes on either side of the joint. On the outside is the lateral collateral ligament complex, while the inside of the elbow is supported by the medial collateral ligament complex. These ligaments can be injured during a fall, elbow dislocation or sporting injury.
Some injuries heal successfully with appropriate protection and rehabilitation. More significant tears, particularly when identified early, may occasionally be suitable for direct ligament repair. If instability has been present for longer and the original ligament is no longer suitable for repair, reconstruction may be necessary using a tendon graft or, in selected situations, a synthetic ligament augmentation.
Elbow instability does not always feel like the joint is completely dislocating. Some patients describe something much subtler — a feeling that the elbow shifts, gives way or feels unreliable when pushing themselves up from a chair or pushing through the arm. That particular history can be an important clue to posterolateral rotatory instability associated with injury to the lateral ligament complex.
Finding the cause of your elbow pain
The same area of elbow pain can arise from a tendon, a nerve, the joint itself or an injured ligament. An MRI or nerve-conduction study can provide useful information, but it doesn't replace understanding where your symptoms occur, what brings them on and how they affect the way you use your arm.
The first aim is therefore to establish what is actually causing your symptoms. We can then decide together whether the right treatment is reassurance and activity modification, specialist physiotherapy, further investigation, or — in a smaller number of cases — surgery.
