Ulnar neuropathy: evaluation and management


Ulnar neuropathy is commonly encountered, both acutely after elbow trauma and in the setting of chronic compression neuropathy. Careful clinical evaluation and discerning evaluation of electrodiagnostic studies are helpful in determining the prognosis of recovery with nonoperative and operative management. Appreciation of the subtleties in clinical presentation and thoughtful consideration of the timing and type of surgical intervention are critical to optimizing outcomes after treatment of ulnar neuropathy. The potential need for decompression at both the cubital tunnel and Guyon’s canal must be appreciated. Supplementation of decompression with supercharged end-to-side nerve transfer can expedite motor recovery of the ulnar intrinsic muscles in the appropriately selected patient. The emergence of nerve transfer techniques has also changed the management of acute ulnar nerve injuries.

This is a preview of subscription content, access via your institution.

Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2012;7:CD006839.

    PubMed  Google Scholar 

  2. 2.

    Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg [Am]. 2008;33:1314. e1-1314.12.

    Article  Google Scholar 

  3. 3.

    Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89:2591–8.

    Article  PubMed  Google Scholar 

  4. 4.

    Gelberman RH, Yamaguchi K, Hollstien SB, Winn SS, Heidenreich Jr FP, Bindra RR, et al. Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera. J Bone Joint Surg Am. 1998;80:492–501.

    CAS  PubMed  Google Scholar 

  5. 5.

    James J, Sutton LG, Werner FW, Basu N, Allison MA, Palmer AK. Morphology of the cubital tunnel: an anatomical and biomechanical study with implications for treatment of ulnar nerve compression. J Hand Surg [Am]. 2011;36:1988–95.

    Article  Google Scholar 

  6. 6.

    Strauch B, Lang A, Ferder M, Keyes-Ford M, Freeman K, Newstein D. The ten test. Plast Reconstr Surg. 1997;99:1074–8.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg [Am]. 1994;19:817–20.

    CAS  Article  Google Scholar 

  8. 8.

    Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg [Am]. 2008;33:1518–24.

    Article  Google Scholar 

  9. 9.•

    Davidge KM, Gontre G, Tang D, Boyd KU, Yee A, Damiano MS, et al. The “hierarchical” Scratch Collapse Test for identifying multilevel ulnar nerve compression. Hand (N Y). 2015;10:388–95. The addition of topical anesthetic to the scratch collapse test can provide a meaningful understanding of multiple points of compression of the ulnar nerve along its course from the brachium to the distal ulnar tunnel.

    Article  Google Scholar 

  10. 10.

    Brown JM, Mokhtee D, Evangelista MS, Mackinnon SE. Scratch collapse test localizes Osborne’s band as the point of maximal nerve compression in cubital tunnel syndrome. Hand (N Y). 2010;5:141–7.

    Article  Google Scholar 

  11. 11.

    Calfee RP, Manske PR, Gelberman RH, Van Steyn MO, Steffen J, Goldfarb CA. Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms. J Bone Joint Surg Am. 2010;92:2801–8.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Mackinnon SE. Nerve Surgery :Thieme, 2015.

  13. 13.

    Shah CM, Calfee RP, Gelberman RH, Goldfarb CA. Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. J Hand Surg [Am]. 2013;38:1125–30. e1.

    Article  Google Scholar 

  14. 14.

    Padua L, Aprile I, Caliandro P, Foschini M, Mazza S, Tonali P. Natural history of ulnar entrapment at elbow. Clin Neurophysiol. 2002;113:1980–4.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Soltani AM, Best MJ, Francis CS, Allan BJ, Panthaki ZJ. Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery database. J Hand Surg [Am]. 2013;38:1551–6.

    Article  Google Scholar 

  16. 16.

    Adkinson JM, Chung KC. Minimal-incision in situ ulnar nerve decompression at the elbow. Hand Clin. 2014;30:63–70.

    Article  PubMed  Google Scholar 

  17. 17.

    Maki Y, Firrell JC, Breidenbach WC. Blood flow in mobilized nerves: results in a rabbit sciatic nerve model. Plast Reconstr Surg. 1997;100:627–33. discussion 634-5.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Nakamura K, Uchiyama S, Ido Y, Itsubo T, Hayashi M, Murakami H, et al. The effect of vascular pedicle preservation on blood flow and clinical outcome following ulnar nerve transposition. J Hand Surg [Am]. 2014;39:291–302.

    Article  Google Scholar 

  19. 19.

    Goldfarb CA, Sutter MM, Martens EJ, Manske PR. Incidence of re-operation and subjective outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379–83.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.•

    Krogue JD, Aleem AW, Osei DA, Goldfarb CA, Calfee RP. Predictors of surgical revision after in situ decompression of the ulnar nerve. J Shoulder Elbow Surg. 2015;24:634–9. The revision rate after in situ decompression for cubital tunnel syndrome was 19% in this series, with 77% of the revisions were performed within 2 years of the in situ decompression. Risk factors for revision surgery after in situ decompression included prior elbow fracture or dislocation and surgery performed for patients with mild symptoms and no motor weakness.

    Article  PubMed  Google Scholar 

  21. 21.•

    Aleem AW, Krogue JD, Calfee RP. Outcomes of revision surgery for cubital tunnel syndrome. J Hand Surg [Am]. 2014;39:2141–9. In this series reporting outcomes after revision surgery following prior cubital tunnel procedures, approximately half of patients had persistence of constant symptoms and worse patient-reported outcomes than those undergoing primary surgery. With these findings in mind, we make every effort to perform a complete decompression and provide a tension-free path for the transposed nerve with no points of new compression or kinking.

    Article  Google Scholar 

  22. 22.

    Mackinnon SE, Novak CM. Compression Neuropathies. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, ed. Green’s Operative Hand Surgery. 6th Edition ed.: Churchill Livingstone, 2005:977.

  23. 23.

    Mackinnon SE, Novak CB. Operative findings in reoperation of patients with cubital tunnel syndrome. Hand (N Y). 2007;2:137–43.

    Article  Google Scholar 

  24. 24.

    Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve transfers to restore ulnar motor and sensory function within the hand: technical nuances. Neurosurgery. 2009;65:966–77. discussion 977-8.

    Article  PubMed  Google Scholar 

  25. 25.•

    Davidge KM, Yee A, Moore AM, Mackinnon SE. The supercharge end-to-side anterior interosseous-to-ulnar motor nerve transfer for restoring intrinsic function: clinical experience. Plast Reconstr Surg. 2015;136:344e–52e. In the appropriately-selected patient, adding an end-to-side nerve transfer of the anterior interosseous nerve to the ulnar motor nerve can augment recovery of motor function in patients with chronic compression neuropathy of the ulnar nerve.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30:253–63.

    Article  PubMed  Google Scholar 

  27. 27.

    Cain Jr EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter 2nd JC, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426–34.

    Article  PubMed  Google Scholar 

  28. 28.

    Waugh RP, Pellegrini Jr VD. Ulnar tunnel syndrome. Hand Clin. 2007;23:301–10. v.

    Article  PubMed  Google Scholar 

  29. 29.

    Phillips BZ, Stockburger C, Mackinnon SE. Ulnar nerve transection during Tommy John surgery: novel findings and approach to treatment. Hand (N Y). 2015;10:555–8.

    Article  Google Scholar 

  30. 30.

    Poppler LH, Davidge K, Lu JC, Armstrong J, Fox IK, Mackinnon SE. Alternatives to sural nerve grafts in the upper extremity. Hand (N Y). 2015;10:68–75.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Susan E. Mackinnon.

Ethics declarations

Conflict of interest

Christopher J. Dy and Susan E. Mackinnon declare that they have no conflict of interest.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Elbow Soft Tissue Surgery

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dy, C.J., Mackinnon, S.E. Ulnar neuropathy: evaluation and management. Curr Rev Musculoskelet Med 9, 178–184 (2016). https://doi.org/10.1007/s12178-016-9327-x

Download citation


  • Cubital tunnel
  • Guyon’s canal
  • Ulnar neuropathy
  • Ulnar nerve transposition
  • Ulnar nerve compression