Ulnar Nerve and Golfers Elbow Pain

Ulnar nerve entrapment is a common and often overlooked problem with wrist pain and or elbow pain. The issue of ulnar entrapment often fall through cracks in healthcare.  The cases that are missed can sometimes result in surgical cases that could have been avoided and easily addressed with specialized manual therapy.

Ulnar nerve entrapment is effectively detected with a manual soft tissue specialization like Active Release Techniques.  X-Rays, or MRI’s and nerve conduction studies don’t reveal the nature of the problem.  Finding the site where the ulnar nerve does not move freely relative to it’s surrounding tissue requires a therapist to have the knowledge-base and experience to detect the problem.

Once the problem is effectivly detected with the hands of the therapist, proper mobilization of the nerve with emphasis on breaking up the adhesion that causes the entrapment is key.  This differs from the conventional nerve mobilization techniques that “floss” or mobilize the nerve with stretching it back and forth.  The additional step of addresses the adhesion can make a dramatic difference is results.

The following is an example of a common case of ulnar nerve entrapment:

Subjective:
A 42-year-old heavy equipment operator reports chronic elbow and wrist pain.  The onset of pain began after long hours working on a new machine that had a new layout of the hand controls.  He has been dealing with this issue for approximately three months.  He sought an orthopedic and medical evaluation for the condition.  A golfer’s elbow diagnosis was made and several weeks of physical therapy and an elbow strap was recommended to alleviate symptoms.

Where does it hurt?
He draws his finger along the ulnar side of his proximal elbow and wrist.

Do any motions make it worse or better?
He identifies that it is uncomfortable for him to straighten his arm.

Do you every have any type of numbness, if so where?
He indicates that his 3rd and 4th fingers is currently numb which is worsened with leaning on a chair armrest

Benchmarks Identified for Treatment
Immediate reduction in symptoms of numbness.
Decrease in symptom onset with leaning on armrest of a chair.

The Objective Checklist:

  • Palpation of passive qualities of elbow extension, flexion pronation and supination.
  • Palpation of passive qualities of wrist, extension, flexion, pronation and supination.
  • Observation of active qualities such as grip in elbow flexion and extension, pronation and supination.

Assessment:
Palpation of relative motion of tissue.  Noted restricted relative motion of multiple structures including medial septum, brachialis, tricep, fcu, pronator teres, pronator quadratus.  Multiple sites of ulnar nerve entrapment most distinctive at the pronator quadratus and distal FCU (Flexor Carpi Ulnaris).

The Treatment:
Protocols to decrease tissue texture and tension consistent with adhesion to restore tissue relative motion.

Ulnar long tract protocols at the site of restricted relative motion of soft tissues.

Treatment Results:

  • Immediate reduction in symptoms of numbness.
  • Arm straightening was described as comfortable
  • 10 minutes after treatment fingers were no longer numb.
  • A sustained testing of leaning on the elbow provoked no symptoms

Next Visit:

  • Expect report in follow-up visit on the benchmark of leaning on a chair armrest and symptoms of grip and straightening the arm.
  • Reassess

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