Introduction

Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve that occurs due to anatomical compression at the medial aspect of the elbow. 

Clinically, it is diagnosed by the presence of sensory changes such as numbness and tingling in the ring and little fingers, as well as intrinsic muscle weakness of the hand and a positive Tinel’s sign over the cubital tunnel. 

Treatment options depend on the severity and duration of symptoms, as well as the response to initial management. Nonoperative approaches, including activity modification, bracing, and anti-inflammatory medications, are often tried first. 

If these measures fail or if symptoms are severe or longstanding, surgical decompression of the ulnar nerve may be considered.

Epidemiology

Cubital tunnel syndrome is a common condition, with an annual incidence of approximately 30 cases per 100,000 people2. It is the second most frequent compression neuropathy affecting the upper extremity, following carpal tunnel syndrome.19

Demographically, cubital tunnel syndrome occurs more often in men than women, with men experiencing a slightly higher incidence rate (31.2 versus 28.8 cases per 100,000 person-years).19 However, among individuals under 50 years old, women are more likely to be diagnosed than men (20.9 versus 19.5 cases per 100,000 person-years).19 In both sexes, the likelihood of developing cubital tunnel syndrome increases with age.19

Etiology

Cubital tunnel syndrome is caused by compression and traction on the ulnar nerve as it passes through the elbow region. The most frequent site of entrapment is between the two heads of the flexor carpi ulnaris (FCU) muscle, specifically at the aponeurosis, which forms the roof of the cubital tunnel. The other most common site include the area between Osborne’s ligament and the medial collateral ligament (MCL) of the elbow.3

Less commonly, the ulnar nerve can be compressed at several other anatomical locations. These include the arcade of struthers, the medial head of the triceps, the medial intermuscular septum, the medial epicondyle, and fascial bands within the FCU. An anomalous muscle called the anconeus epitrochlearis, which extends from the medial olecranon to the medial epicondyle, can also contribute to nerve compression. Additionally, the aponeurosis at the proximal edge of the flexor digitorum superficialis (FDS) may be involved in rare cases.3

External sources of compression are also recognized contributors to cubital tunnel syndrome. These include fractures and nonunions of the medial epicondyle, osteophytes, heterotopic ossification, and the presence of tumors or ganglion cysts. Such external factors can further narrow the space available for the ulnar nerve, increasing the risk of entrapment and subsequent symptoms.3

• Associated conditions include cubitus varus or valgus deformities, medial epicondylitis, burns and elbow contracture release. 

Anatomy

Ulnar nerve 

The nerve arises from the medial cord of the brachial plexus, specifically from the C8 to T1 nerve roots. In the anterior compartment of the upper arm, it lies posteromedial to the brachial artery. Approximately 8 cm proximal to the medial epicondyle, the nerve pierces the intermuscular septum at the arcade of Struthers. It then runs behind the medial epicondyle, passing through the cubital tunnel. Upon entering the forearm, the nerve travels between the two heads—humeral and ulnar—of the flexor carpi ulnaris (FCU). It continues its course between the FCU and the flexor digitorum profundus (FDP) muscles. As it approaches the wrist, the nerve passes superficial to the transverse carpal ligament.

Cubital tunnel 

• roof
• formed by FCU fascia and Osborne's ligament (travels from the medial epicondyle to the olecranon)
• floor
• formed by posterior oblique and transverse bands of MCL and elbow joint capsule 
• walls
• formed by medial epicondyle and olecranon

Classification

McGowan and Dellon classification for cubital tunnel syndrome.

Clinical Presentation

Symptoms

Cubital tunnel syndrome typically presents with numbness and tingling in the ring and little fingers, often worsening when the elbow is bent, such as during prolonged cell phone use or while sleeping.2 Patients may also experience pain localized to the inner aspect of the elbow, specifically in the area of the cubital tunnel.2 As the condition progresses, there can be a noticeable loss of intrinsic muscle strength in the hand, leading to weakness, clumsiness, and sometimes cramping of the small hand muscles.2 Activities that exacerbate symptoms commonly include those requiring repetitive or sustained elbow flexion and valgus stress, such as certain occupational or athletic tasks and frequent use of handheld devices.2 In more severe or chronic cases, muscle wasting and persistent functional impairment may develop if the nerve compression is not addressed.2

Symptom duration usually comes on insidiously over months to years. But it can occur out of nowhere. Sometimes they’ll describe that they were leaning on the elbow for an extended period of time while driving or on a long plane ride. Sometimes the patient will describe a night out on the town and leaning on their elbow all night long. These cases were normal prior to the incident and will usually resolve on their own with time. 

It is important to note that cubital tunnel syndrome does not present with numbness in the forearm. Numbness in the forearm comes from the brachial plexus and the medial brachial cutaneous nerve. 

 Distinct sensory areas supplied by the hand’s nerves.

Physical Exam

Physical examination for patients with suspected cubital tunnel syndrome involves inspection and palpation, which may reveal:

Inspection & Palpation3,

• Atrophy of the interosseous muscles and first web space
• Clawing of the ring and small fingers
• Observation of ulnar nerve subluxation over the medial epicondyle during elbow flexion and extension

Sensory

• Sensory findings, such as reduced sensation in the ulnar one and a half digits

Motor3,4

Motor deficits following ulnar nerve injury result in paralysis of several intrinsic hand muscles, including the adductor pollicis, deep head of flexor pollicis brevis, interossei, and the third and fourth lumbricals. This leads to:

• Weakened grip strength due to loss of metacarpophalangeal (MP) joint flexion power.
• Reduced pinch strength, primarily from impaired thumb adduction; up to 70% of pinch strength may be lost.
• Positive Froment’s sign: During key pinch, the patient compensates for loss of thumb adduction (normally performed by adductor pollicis, innervated by the ulnar nerve) by flexing the thumb’s interphalangeal (IP) joint using the flexor pollicis longus (innervated by the anterior interosseous nerve, a branch of the median nerve).
• The adductor pollicis typically functions as a metacarpophalangeal (MCP) flexor, first metacarpal adductor, and IP extensor.
• Jeanne’s sign: Compensatory hyperextension of the thumb MCP joint and adduction by the extensor pollicis longus (radial nerve) during key pinch, compensating for loss of IP extension and thumb adduction by the adductor pollicis.
• Wartenberg’s sign: Persistent abduction and extension of the small finger during attempted adduction, due to weakness of the third palmar interosseous and the small finger lumbrical.
• Masse’s sign: Flattening of the palmar arch and loss of ulnar hand elevation, secondary to weakness of the opponens digiti minimi and decreased small finger MCP flexion.
• Extrinsic muscle weakness may also be present.
• Pollock’s sign: Inability to flex the distal interphalangeal joints (DIPJ) of the ring and small fingers, reflecting weakness of the flexor digitorum profundus.

These characteristic signs and compensatory mechanisms reflect the loss of fine motor control and strength in the hand following ulnar nerve injury, particularly affecting grip, pinch, and coordinated finger movements.

Provocative Tests

Provocative tests for diagnosing cubital tunnel syndrome include:5,6

• Tinel’s sign: Elicited by tapping over the cubital tunnel; a positive result is the reproduction of tingling or numbness along the ulnar nerve distribution.
• Elbow flexion test: The patient fully flexes the elbow, often with the wrist extended, and holds this position for up to 60 seconds or longer; the test is positive if symptoms such as pain, numbness, or tingling are reproduced in the ulnar nerve distribution.
• Direct compression test: Applying pressure over the cubital tunnel, especially during elbow flexion, can exacerbate symptoms and is considered positive if it reproduces the patient’s typical complaints.
• The Scratch-Collapse Test (SCT) is a clinical maneuver used to help diagnose cubital tunnel syndrome, which is caused by compression of the ulnar nerve at the elbow. The test is valued for its higher sensitivity compared to traditional provocative tests like Tinel’s sign and the elbow flexion test.6

Test Procedure

• The patient is seated with arms at their sides and elbows flexed to 90 degrees.
• The examiner asks the patient to resist bilateral shoulder external rotation (the examiner tries to rotate the patient’s forearms outward while the patient resists).
• After establishing baseline resistance, the examiner lightly scratches or strokes the skin over the suspected site of ulnar nerve compression (commonly at the cubital tunnel, near the medial epicondyle).
• Immediately after the scratch, the examiner repeats the resisted shoulder external rotation.
• A positive test is indicated by a brief, involuntary loss of resistance (collapse) on the affected side, which is thought to be due to a momentary inhibition of muscle activity caused by the nerve irritation.

Interpretation and Utility

• A positive SCT suggests the presence of ulnar nerve compression at the site tested.
• The test can help localize the point of maximal compression, often at Osborne’s band within the cubital tunnel.
• The SCT has demonstrated a sensitivity of about 69% for cubital tunnel syndrome, which is higher than Tinel’s test (54%) and the elbow flexion compression test (46%).
• The test is particularly useful for clinicians familiar with the surface anatomy of the ulnar nerve and can be used in conjunction with other diagnostic maneuvers.
• The SCT is always performed first over a control area (such as the lateral deltoid) to establish a negative control.

Illustration of the Scratch Collapse Test technique, which was modified after the initial technique, was published by Cheng et al. in 2008.6

EMG / NCS

Electromyography (EMG) and nerve conduction studies (NCS) are valuable tools in both establishing the diagnosis and determining the prognosis of cubital tunnel syndrome.7 These tests provide objective evidence of ulnar nerve dysfunction and help to localize the site of compression. In the diagnostic process, nerve conduction studies specifically measure the speed and strength of electrical signals traveling along the ulnar nerve across the elbow. A conduction velocity of less than 50 meters per second (m/sec) across the elbow is generally considered the threshold for diagnosing cubital tunnel syndrome.7 Additionally, low amplitudes of sensory nerve action potentials and compound muscle action potentials detected during these studies further support the diagnosis by indicating impaired nerve function.7 The results of EMG and NCS not only confirm the presence of nerve compression but also assist in assessing the pre- and post-operative outcomes, particularly if they do not respond to surgery.7

Radiographic Evaluation

Radiographs (X-rays) of the elbow are obtained in patients suspected of cubital tunnel syndrome primarily to evaluate the bony anatomy and identify potential structural causes of ulnar nerve compression. While cubital tunnel syndrome is a neuropathy caused by compression of the ulnar nerve at the elbow, the underlying cause can often be related to bony abnormalities or degenerative changes. 

• X-rays can reveal bone spurs (osteophytes), arthritis, previous fractures, or other deformities in the elbow region that may contribute to narrowing of the cubital tunnel and compression of the ulnar nerve.8
• Assessing Cubital Tunnel Anatomy: Specialized X-ray views, such as the cubital tunnel view (an anteroposterior view with full flexion and 20 degrees of external rotation), allow visualization of the bony structure of the cubital tunnel. Measurements such as the cubital tunnel angle (CTA) and cubital tunnel depth (CTD) can be used to assess whether anatomical variations increase the risk of nerve irritation.8
• Ruling Out Other Pathologies: Radiographs help exclude other potential causes of symptoms, such as tumors, fractures, or joint dislocations, which could mimic or contribute to ulnar nerve compression.8

Magnetic Resonance Imaging

MRI is not the first-line diagnostic tool for cubital tunnel syndrome. It is reserved for cases with atypical features, inconclusive standard testing, suspicion of structural lesions, or for preoperative assessment.7 

Ulnar nerve thickening and increased T2 signal intensity at the cubital tunnel.7 Loss of normal fascicular pattern, edema-like signal changes, or muscle atrophy secondary to chronic nerve compression.7 Identification of structural abnormalities, such as bone spurs or masses causing compression.7

For most patients with classic symptoms and confirmatory electrodiagnostic studies, MRI is not routinely indicated.

Ultrasound

Ultrasound is commonly used in the evaluation and diagnosis of cubital tunnel syndrome (CuTS), which involves compression of the ulnar nerve at the elbow. High-resolution neuro-ultrasonography can detect changes in the size, position, and echotexture of the ulnar nerve, helping to identify nerve swelling or compression.9 Ultrasound can also be used to measure the cross-sectional area (CSA) of the nerve, which may indicate nerve entrapment.9

Differential Diagnosis

Ulnar Tunnel Syndrome

Cubital tunnel syndrome, a condition involving compression of the ulnar nerve at the elbow, must be differentiated from other disorders such as ulnar tunnel syndrome and C8 radiculopathy.2 Key clinical features help distinguish cubital tunnel syndrome from ulnar tunnel syndrome. In cubital tunnel syndrome, patients typically exhibit less clawing of the hand, sensory deficits that extend to the dorsum of the hand, and motor deficits affecting ulnar-innervated extrinsic muscles. Provocative tests such as a positive Tinel sign at the elbow and a positive elbow flexion test are also characteristic of cubital tunnel syndrome.2 In contrast, ulnar tunnel syndrome, which involves compression of the ulnar nerve at the wrist (Guyon’s canal), does not produce sensory loss on the dorsum of the hand or affect extrinsic muscles, and clawing is more pronounced.

C8 Radiculopathy

When distinguishing cubital tunnel syndrome from C8 radiculopathy, further clinical findings are important. Cubital tunnel syndrome often presents with weakness in flexion of the distal phalanges of the middle and index fingers, leading to difficulty with fine motor tasks, as well as paresthesias in the ring and little fingers. In contrast, symptoms of C8 radiculopathy may improve with shoulder abduction, and the pattern of muscle weakness and sensory loss differs due to the involvement of nerve roots rather than the peripheral ulnar nerve.20 Careful examination of muscle strength and sensory distribution, along with provocative testing, is essential for accurate diagnosis and appropriate management.

Nonoperative Management

Activity Modification and Education

Patients are advised to avoid activities that keep the elbow bent for prolonged periods or that place direct pressure on the inside of the elbow, such as resting the elbow on hard surfaces or sleeping with the elbow flexed. Ergonomic adjustments at work and home, along with education on nerve-protective postures, are central to this approach. These modifications help reduce irritation of the ulnar nerve and can lead to significant symptom improvement, particularly in mild to moderate cases.15 Studies show that activity modification alone can result in functional improvement, with some patients reaching a plateau in symptoms after several months.

Nighttime Elbow Splinting

Wearing a padded brace or rigid splint at night holds the elbow in a position of extension (typically around 45 degrees of flexion), preventing excessive bending during sleep. This reduces pressure on the ulnar nerve and can alleviate numbness and tingling. Clinical evidence supports the use of night splinting, especially when combined with activity modification, with studies reporting that up to 88% of patients with mild to moderate symptoms can avoid surgery after three months of this regimen.16 Compliance with splinting is crucial for optimal results.

NSAIDs and Anti-inflammatory Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to manage pain and inflammation associated with cubital tunnel syndrome. While NSAIDs can help with discomfort, they do not address the underlying nerve compression and are generally considered adjunctive to other non operative measures.

Physical Therapy and Nerve Gliding Exercises

Physical therapy often includes nerve gliding exercises, which are designed to improve the mobility of the ulnar nerve within the cubital tunnel, as well as stretching and strengthening exercises to support the muscles around the elbow. These interventions are purported to help reduce symptoms and improve function, although the evidence for their effectiveness is less robust compared to activity modification and splinting.17 However, results are mixed when comparing nerve gliding directly to standard care or splinting, with some studies showing no significant additional benefit.18 The quality of evidence varies, with several studies rated as moderate to low quality due to methodological limitations.18

Outcomes

Nonoperative management—particularly the combination of activity modification and night splinting—has been shown to be effective in the majority of patients with mild to moderate cubital tunnel syndrome. Studies report high rates of symptom resolution and functional improvement, with 82% to 88% of patients avoiding surgical intervention over follow-up periods of up to two years.16 The recommended duration for a trial of conservative therapy is typically 3 months, with reassessment to determine if further intervention is needed.

Supplements

There is currently limited direct research specifically on vitamins or supplements for cubital tunnel syndrome (CuTS), which involves ulnar nerve compression at the elbow. Most available research and clinical trials focus on carpal tunnel syndrome (CTS), a related but distinct nerve entrapment condition affecting the median nerve at the wrist. However, some findings from CTS research may be cautiously extrapolated to CuTS due to similarities in nerve compression pathophysiology.11

B-Group Vitamins (e.g., B6, B12)

High-dose B-group vitamins (especially B6 and B12) have been studied for nerve health and neuropathy. There is moderate evidence that B-group vitamins may reduce pain and improve symptoms in nerve compression syndromes like CTS, but the evidence is stronger for CTS than for CuTS.13 Some clinicians recommend B6 (pyridoxine) for nerve health, but robust evidence for CuTS is lacking.

The effectiveness of B vitamins in CTS is controversial, with some studies showing benefit and others showing little to no effect.13 For CuTS, there is no high-quality evidence supporting routine use, but supplementation may be considered in cases of documented deficiency. Bottom line: May help in deficiency; controversial for direct symptom relief

Alpha-Lipoic Acid and Curcumin

Alpha-lipoic acid and curcumin, both with antioxidant and anti-inflammatory properties, have demonstrated benefit in CTS when combined with B-group vitamins, showing reduced symptoms and improved patient satisfaction.12 There is no direct evidence for CuTS, but their role in nerve regeneration and inflammation suggests potential benefit.

These supplements are generally considered safe and may be tried as adjuncts, but direct research in CuTS is needed. Bottom line: Antioxidant, anti-inflammatory; some benefit in CTS, not studied in CuTS.

Vitamin D

Vitamin D supplementation has shown favorable outcomes in CTS, including pain reduction and improved nerve conduction.14 There is no direct evidence for CuTS, but maintaining adequate vitamin D levels is generally recommended for overall nerve and musculoskeletal health. Bottom line: Supports nerve health; benefit shown in CTS, not studied in CuTS.

Operative Management

Cubital tunnel syndrome treatment depends on symptom severity and nerve involvement. Surgical options vary based on specific clinical scenarios, with key procedures including in situ decompression, anterior transposition, and medial epicondylectomy. Below is an organized summary of indications and outcomes for each approach:

In Situ Ulnar Nerve Decompression

Indications include:

• Failure of nonoperative management (rest, splinting, NSAIDs).21
• Early intervention before motor denervation occurs.21

Outcomes include:

• 80-90% success rate when treating intermittent symptoms without muscle atrophy.21
• Meta-analyses show equivalent clinical results to transposition with fewer complications (e.g., reduced wound issues).22
• Poor prognosis strongly correlates with preoperative intrinsic muscle atrophy.23

Ulnar Nerve Anterior Transposition

Indications include:

• Failed in situ decompression.24
• Throwing athletes requiring nerve stabilization.24
• Compromised nerve bed from osteophytes, tumors, or heterotopic bone.24

Outcomes include:

• Comparable symptom relief to in situ decompression but higher complication risk (15-25% vs. 10-12%).24
• Particularly effective for pediatric patients with nerve instability.24
• May create new compression sites if improperly executed.24

Nerve Recovery Timeline

• Motor conduction velocity typically normalized within 2 weeks post-decompression.23
• Distal latency improvements depend on early surgical intervention.23

Medial Epicondylectomy

Indications include:

• Symptomatic ulnar nerve subluxation visible during elbow flexion.25
• Thin patients lacking subcutaneous tissue for transposition.25

Outcomes include:

• Risk of medial elbow instability due to potential medial collateral ligament damage.25
• Effective nerve decompression but limited by postoperative stability concerns.25

Nonoperative management remains first-line for mild cases, while surgical success depends on timely intervention before irreversible nerve damage occurs. Early decompression preserves nerve function better than delayed treatment, particularly when performed prior to muscle atrophy development.

References

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18. Ballestero-Pérez R, Plaza-Manzano G, Urraca-Gesto A, et al. Effectiveness of Nerve Gliding Exercises on Carpal Tunnel Syndrome: A Systematic Review. J Manipulative Physiol Ther. 2017;40(1):50-59. doi:10.1016/j.jmpt.2016.10.004
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23. Kong L, Bai J, Yu K, Zhang B, Zhang J, Tian D. Predictors of surgical outcomes after in situ ulnar nerve decompression for cubital tunnel syndrome. Ther Clin Risk Manag. 2018 Jan 4;14:69-74. doi: 10.2147/TCRM.S155284. PMID: 29379297; PMCID: PMC5757488.
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