ulnar tunnel syndrome
I am Dr Ashok Shyam .I am a board certified and fellowship trained orthopedic surgeon pracising in Thane , India.
The discussion topic of this hub is ulnar tunnel syndrome
Ulnar tunnel syndrome
As the name suggest it is the affection of the ulnar nerve in its tunnel. The ulnar tunnel liesat the back of the elbow joint on the inner aspect. The most queries aspect of the syndrome and the point of my writing this article is its occurrence in certain occupations.
My guitar teacher had recently visited me with problems of weakness of his left hand. On examination I found that he had a classical ulnar tunnel syndrome
Nerves as we call them are the internal electrical wiring system of the body that carries electrical currents to and fro from the central unit that is the brain. Affections of these electrical cables lead to faulty functions in their area of supply. Many a times like the electrical underground cables these nerves are affected by increased pressure over them. His mostly occurs in where there is congestion from the beginning like a tunnel.
Nerves mostly run from deep to superficial and while passing so go through soft tissue tunnels. Also some nerves like the ulnar nerve pass through Osseo facial tunnels like the back of the elbow. Cubital tunnel syndrome is said to exist when the ulnar nerve is affected at he back of the elbow in its tunnel behind the medial epicondyle
The ulnar nerve controls the hand intrinsic movements and thus controls all the fine movements of the hand. This is the reason why it is called the musician’s nerve. The name also indicates that it’s the musician’s that face the problems associated with this nerve.
In case of guitarists this syndrome is seen mostly in the left hand i.e. the fret board hand. If we analyse the playing of a simple bar chord, we would notice 1) contraction of the thumb against the underside of the neck of the guitar, 2) a counterbalancing contraction of the opposing fingers on the fretted side of the neck, 3) bending of the fingertips to push against the strings, 4) flattening of one finger against the neck to form the bar (usually the first finger),5) maybe some stretching of the little finger to reach a higher fret 6) flexion of the wrist and 7) flexion of more than 90 degrees at the elbow. all this along with the repitive, spontaneous and continuous nature of this movements for a prolonged time causes wear and tear
How does all this affect the nerve
Due to constant use of muscles in all the above activities there may be an overuse injury, unexpected strain or actually a gradual tensioning leading to ‘micro tears’ in the muscles . This might lead to inflammation and swelling around these muscles and the ulnar nerve.
As the elbow moves from extension to flexion, the distance between the medial epicondyle and the olecranon increases 5 mm for every 45° of elbow flexion. The shape of the cubital tunnel changes from a round to an oval tunnel, with a 2.5-mm loss of height, because the cubital tunnel rises during elbow. The cubital tunnel's loss in height with flexion results in a 55% volume decrease in the canal, which further results in the mean ulnar intraneural pressure increasing from 7 mm Hg to 14 mm Hg.
A combination of shoulder abduction, elbow flexion, and wrist extension results in the greatest increase in cubital tunnel pressure, with ulnar intraneural pressure increasing to about 6 times normal.
Traction and excursion of the ulnar nerve also occur during elbow flexion, as the ulnar nerve passes behind the axis of rotation of the elbow. With full range of motion (ROM) of the elbow, the ulnar nerve undergoes 9-10 mm of longitudinal excursion proximal to the medial epicondyle and 3-6 mm of excursion distal to the epicondyle. In addition, the ulnar nerve elongates 5-8 mm with elbow flexion.
All the above movements are associated with skilled guitar playing, thus affecting the guitarist’s nerve
Some comments on pathology
Cubital tunnel syndrome affects men 3-8 times as often as women.
Cubital tunnel syndrome may be caused by
Constricting facial bands
Subluxation of the ulnar nerve over the medial epicondyle
- Numbness in the third or little fingers, which is often worse at night, and may awaken the person from sleep
- Pain from the elbow down the arm and into the third and little fingers, which often gets worse with use of the hand or arm. The pain is usually described as aching or burning.
- Numbness in the fingertips which may feel like "pins and needles" or tingling
- Weakness of the little finger, or weakness of the hand grip
- In severe cases, the fingers may contract (or draw up) and become difficult to extend
strengthening the elbow's flexors and extensors both isometrically and isotonically within 0-45° ROM is helpful.
Limit the arc of elbow motion to an extended range to avoid ulnar nerve impingement in the cubital tunnel.
Recommend that the patient decrease activities of repetition that may exacerbate symptoms.
Administer nonsteroidal anti-inflammatory drugs (NSAIDs) in an attempt to decrease inflammation around the nerve.
Protect the ulnar nerve from prolonged elbow flexion during sleep, and protect the nerve during the day by avoiding direct pressure or trauma.
Recommendations for initial conservative treatment for cubital tunnel are
To use an elbow pad and/or night splinting for a 3-month trial period.
Consider daytime immobilization for 3 weeks if symptoms do not improve with splinting. Consider surgical release if the symptoms do not improve with conservative treatment.
If the symptoms do improve, continue conservative treatment for at least 6 weeks beyond the resolution of symptoms to prevent recurrence.
For mild cubital tunnel symptoms, a reversed elbow pad that covers the antecubital fossa, rather than the olecranon, serves as a reminder to the patient to maintain the elbow in an extended position and to avoid pressure on the nerve. At night, position a pillow or folded towel in the antecubital fossa to keep the elbow in an extended position. Another option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms.
For constant pain and paresthesia, consider a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times. As symptoms subside, patients can wear the splint just at night.
If conservative therapy fails, treatment of cubital tunnel syndrome may consist of simple
1.in situ decompression,
2. In situ decompression with medial epicondylectomy
3. Anterior transposition of the ulnar nerve
The whole idea of writing for hub pages about health topics is to fore warn the reader.
An Ounce of Prevention Is Worth a Pound of Surgery
Most of the disorders are preventable and my emphasis is always on preventive orthopedics.
So what's a guitarist supposed to do to do?
For those of you who do not have symptoms
and would like to prevent them from ever occurring, there's a few simple steps to take:
- Take frequent breaks while playing [10 mins rest for every 45 mins playing]. The constant playing without resting causes the micro tearing of the muscles and the resulting repetitive strain.
- Before you play and during your breaks, increase blood flow to the forearm and hands by stretching and performing self-massage to the area. A simple rolling of the shoulder or repitive flexion extension of the wrist may do the trick. Avoid flexion extension of the elbow!!
If you do have the symptoms mentioned above:
- Use heat on the forearm before practicing, and ice the elbow and forearm area after playing. The heat will encourage more blood to the tissues while playing, and the ice will discourage swelling afterwards. Perform stretching to the forearm three to four times daily.
- If you are experiencing nerve related symptoms like tingling and numbness, see a health professional immediately who is experienced in treating musician's injuries. Many musician's make the mistake of seeing their general practictioner who is not trained about treating repetitive strain injuries. Ask the doctor or therapist if they have treated similar cases, and what type of results they achieved.
- Always try conservative measures first [ listed below]. Give yourself at least six to eight weeks to heal.
- If you notice symptoms worsening, or weakness occurring in the hands, your health care provider should refer you to a medical doctor for a consultation and neurological testing.
- Nerve-related conditions are serious because the nerve can actually die due to compression and decreased blood flow. This could lead to a permanent disability in your forearm and hand - not what a guitarist needs!
- If you have a job that requires repetitive motion with the arm, make sure you have adequate support (i.e. elbow pads)
- Avoid repetitive leaning on your elbow when using the telephone.
- Avoid resting your elbow on the window or door frame while driving
- Perform frequent stretching exercises i.e.: stretch the arm 10 times every hour, or squeezing a small rubber ball several times per day.
- Keep your weight within normal limits for your age and height
- Avoid injury to the elbow (ie: wear protective equipment when roller-skating)
- Try using an arm support at the keyboard or typewriter if you type often
- If you are diabetic, try to keep your blood sugar under adequate control
Other measures one can use
- "Over the counter" non-steroidal anti-inflammatory medication (NSAID), such as aspirin, ibuprofen, naprosyn, or ketoprofen.Check with your pharmacist regarding possible side effects and drug interactions.
- Take Vitamin B6 100 mg daily (not more) - controversial, but can't hurt, and might help. If you are pregnant or receiving vitamin therapy already, first check with your doctor.
- A splint or brace use while sleeping to keep the elbow from bending while you sleep - there are several home remedies which may be tried at bedtime:
- Wrap a towel around the elbow, like a "pig in a blanket", and hold in place with tape or safety pins.
- Use a small size soft knee splint from a sports store, but wear it on the elbow.
- Tie a scarf around your waist and then around your wrist.
- Watch and modify your posture during the day to avoid long periods of time with your elbow bent. If you work at a desk, make more space between your work and your chest, so that your elbows are more straight more often.
Among the other common causes of cubital tunnel syndrome are:
- Using a computer
- Sleeping on bent elbows
- Repetitive factory work
- Long-distance driving
- Playing other musical instrument
A group of hobbyists known as speed-cubists who solve Rubik's Cubes
- Use of power tools
- Construction work such as handling many bricks, stone and/or lumber
I had found a few suggestions made by a programmer who had cubital tunnel syndrome like wearing wrist braces while programming and an elbow splint while sleeping. I think they are quite helpful and am mentioning them here.
Tools and technologies that can help to accomplish more work with fewer arm and finger movements. Suggested tools include:
- Touch screen monitor
- Split keyboards
- Vertical mice such as the 3M Ergonomic Mouse
- Programmable keyboards such as X-Keys
- Keyboard shortcuts
- Program and file launcher
- Voice recognition software
- Macro software
- Automated build software
The true impact of these modification is yet to be sudied in detail, however I suggest they are helpful in prevention rather than treatment of the cubital tunnel syndrome
Any further inquiry in to the topic is welcomed. I have consciously avoided the medical jargon from this hub but further need of knowledge is appreciated. critical comments are welcomed too.