Hello, sethro-ga!
You’re question is definitely intriquing. What is most impressive is
that you seem to be a person who takes charge and tries to find out as
much as possible about your condition and diagnosis, and one who is
not willing to merely give up and “live with it!” That is an admirable
quality, and I imagine it has gotten you far in many areas of your
life!
Since I am an active person myself, I can certainly sympathize with
your inability to perform certain exercises without nerve pain. It
would frustrate me to no end. I have also dealt with several
conditions of my own that have severely taxed my pain threshold and
exercise ability, and which prompted me to seek every alternative
therapy available, and, in one instance, have surgery. Therefore, I am
with you all the way on trying to find some answers.
With that said……I cannot dispense medical advice. I am not a doctor,
or even close to one. Therefore, any information I can uncover for you
is merely for research purposes, and for your help in your own medical
“sleuthing.”
The following article exerpts should give you some references to
ulnar nerve compression and displacement, possible causes, and
possible alternatives to therapy.
The first site I went to was www.emedicine.com , where I searched
under “ulnar nerve irritation.” Some excerpts from the article titled
“Ulnar Nerve Entrapment,” by Mark Stern MD. (7/29/2002) at
http://www.emedicine.com/orthoped/topic574.htm follow:
“Due to the anatomical positioning of the ulnar nerve, it is subject
to entrapment and injury by a wide variety of causes. It is the second
most common entrapment neuropathy in the upper extremity (the first
being the median nerve and its branches). Because of its superficial
position at the elbow, it often is injured by excessive pressure in
this area (leaning on the elbow during work or while driving a car).”
“Posner has defined 5 areas of potential compression around the
elbow as follows:”
(Out of the following 5 areas, I have excerpted two which sound
similar to the condition you describe)
“The olecranon or epicondylar groove is a fibroosseous tunnel
holding the ulnar nerve and its vascular accompaniment. A congenitally
shallow groove or a torn fibrous roof can allow the nerve to
chronically subluxate or dislocate, causing neuritis and palsy.
Fracture fragments and arthritic spurs in or around the groove
impinging on the nerve also can cause entrapment and subsequent
neuritis. Traumatic hemorrhage, soft-tissue tumors, ganglia,
infections, osteochondromas, synovitis secondary to rheumatoid
diseases, and malposition during work or sleep all may cause
entrapment and nerve dysfunction.” (You say you can feel the nerve
“pop out of the groove,” so this seems to describe your “condition”)
“The cubital tunnel is the passage between the 2 heads of the flexor
carpi ulnaris, which are connected by a continuation of the
fibro-aponeurotic covering of the epicondylar groove (Osborne
ligament). During elbow flexion, the tunnel flattens as the ligament
stretches, causing pressure on the ulnar nerve.” (You mentioned the
doctor’s have told you that the ligament, which holds the nerve in
place “stretches.”)
Clinical: “Presenting symptoms can vary from mild transient
paraesthesias in the ring and small fingers” (which seems to describe
the degree to which the nerve pain has affected you)
"to clawing of these digits and severe intrinsic muscle atrophy.
There may be severe pain at the elbow or wrist with radiation into the
hand or up into the shoulder and neck. Patients may complain of
difficulty in opening jars or turning doorknobs. Early fatigue or
weakness may be noticed if work requires repetitive hand motions. If
the patient rests on the elbows at work, increasing numbness and
paraesthesias may be noticed throughout the day.”
(Later in the article, the author states that numbness is a
precursor to motor loss, and that “Muscle wasting and clawing of the
ring and small digits are indicative of a chronic compressive
syndrome.” It doesn’t seem that you are in the chronic compressive
state, thankfully, since your symptoms are aligned with certain arm
positions.)
“A careful clinical history is imperative, noting the time of
occurrence of symptoms. Are they transient or continuous? Are they
related to work, sleep, or recreation?”
(You have done a good job of discerning when the symptoms occur,
which is primarily when the arm is pushing while in a flexed
position.)
Non-surgical therapy
Intermixed with lengthy discussions of diagnostics, imaging, lab
tests, surgical options and contraindications, are a few paragraphs
devoted to non-surgical methods of therapy from which I have gleaned
the following suggestions:
“Nonsteroidal anti-inflammatory medications also are useful adjuncts
to relieve nerve irritation.”
“Oral Vitamin B-6 supplements may be helpful for mild symptoms.”
“..anterior elbow extension splinting (if necessary)”
“….correction of ergonomics at work.”
“This treatment should be carried out for 6-12 weeks, depending on
patient response. Surgical intervention is indicated if increasing
paresthesiae occurs despite adequate conservative treatment, and at
the first sign of motor changes.”
Excerpts from another article titled “Nerve Entrapment Syndromes,” by
Dachling Pang MD. (10/4/2001) at
http://www.emedicine.com/med/topic2909.htm follow:
Ulnar Entrapment at the Elbow:
“Ulnar neuropathy at the elbow may be posttraumatic or
nontraumatic. Trauma may be a single event or in mild repetitive form;
the pathophysiological basis for the traumatic neuropathy likely is
scarring and adhesion at the cubital tunnel or under the flexor carpi
ulnaris aponeurosis. Patients with nontraumatic ulnar neuropathy often
have jobs that require repetitive elbow flexion and extension or
prolonged resting of the elbow on a hard surface, such as a desk.
Elbow flexion narrows the cubital tunnel because of traction on the
arcuate ligament and bulging of the medial collateral ligament. The
nerve also elongates with elbow flexion, increasing intraneural
pressure.”
(From the above, I would ask…have you had some trauma to both
elbows? If not, what aspects of your life, in terms of job or
activities, have required “repetitive elbow flexion and extension,” or
pressure on the elbows from a hard surface?)
“Spontaneous subluxation of the ulnar nerve out of the cubital
tunnel occurs in 15% of the population, which may aggravate symptoms
of entrapment by the rubbing action exerted by the bony surfaces.”
“Early symptoms include intermittent paresthesia along the ring and
little fingers and discomfort along the medial aspect of the forearm.
Pain usually comes later, as a deep ache around the elbow region, and
often is exacerbated suddenly when the medial elbow is brushed
accidentally. Gentle tapping of the nerve at and around the cubital
tunnel elicits distressing electrical shock and/or tingling down the
ulnar fingers. There may be diminished sensitivity to pinprick, light
touch, and 2-point discrimination on the ulnar pad of the fifth finger
and along the ulnar split-half of the fourth finger. Provocative test
with sustained elbow flexion or combined with gentle digital pressure
on the cubital tunnel brings out the symptoms of paresthesia and pain.
Weakness of finger abductors and adductors is variable.”
“Late symptoms include dense numbness and profound weakness and
atrophy of the intrinsic hand muscles. The last 2 digits assume the
classic ulnar claw hand, with extension at the metacarpal phalangeal
joints and flexion at the intraphalangeal joints. The old, "burnt out"
neuropathic hand often is atrophic, weak, and thin-skinned but,
surprisingly, painless and free of other sensory phenomena.”
Non-surgical intervention:
“Conservative management includes elbow splint at night, elbow
padding for the habitual "elbow resters," and modification of
work-related repetitive elbow flexion.”
Refer to the entire article for descriptions of surgical procedures
and outcomes.
Another non-surgical treatment is the injection of cortisone (though
this probably won’t help if the nerve is actually jumping out of the
groove). Read “Elbow Disorders: Cubital Tunnel Syndrome.” (2001) at
http://www.orthohospital.org/treatments/tre_elbow.html
Also refer to the article titled “Upper Extremity Nerve Entrapment
Syndromes,” by Alan Clark, MD at
http://www.nursingceu.com/NCEU/courses/nerve/ Scroll down to the
question”
Question: Rodney has seen a lot of median nerve entrapments today.
What about ulnar nerve entrapments - what’s the scoop on these? After
reading about various diagnosic, the treatment options suggested are
as follows:
“Patients who have either mild or intermittent symptoms and who do
not show evidence of motor involvement should be treated
conservatively. Extreme flexion and repetitive flexion and extension
of the elbow should be avoided. Patients must be cautioned not to lean
on their elbows when sitting in an arm chair or at a table or desk.
Night splints or a pillow wrap at the elbow may be used to maintain
elbow extension during steep. NSAIDs also have a role in cubital
tunnel syndrome, but steroid injections must be avoided owing to the
potential for direct nerve damage.”
From the article “Elbow Disorders.” Blount Orthopaedic Clinic LTD at
http://www.blountortho.com/elbowdisorders.html :
Nerve Injuries
“Because the median and radial nerves are covered by muscles around
the elbow, they are rarely involved in problems at the elbow joint.
However, problems can occur with these nerves causing pain at the
elbow as well as numbness or tingling at the wrist and therefore we
must rule out their involvement when evaluating an elbow problem.
Because the ulnar nerve is so superficial it more frequently causes
problems. Patients may have pain directly over the nerve, or pressure
on the nerve may cause numbness and tingling. These sensations are
usually felt in the small and ring fingers. They can occur with
leaning on the elbow, holding the elbow for a prolonged period of time
in a flexed position, or with repetitive flexing of the elbow. The
best way to treat this problem is with avoidance of the irritating
activity. Occasionally the nerve needs to be moved surgically out of
the superficial position that it is in and protected under the flexor
muscle group.”
(Holding your elbow in a flexed position while on the phone and
experiencing nerve pain is not surprising)
From the article “Imaging of the Elbow: an Update” at
http://www.ulb.ac.be/assoc/chorus/orthogenval/2000/abstracts/session7.htm
:
“The ulnar nerve is the most frequently injured nerve about the
elbow. Injuries may occur secondary to nerve traction or compression,
subluxation or direct trauma. Etiologies also include malunited
fractures of the medial epicondyle, thickened cubital tunnel
retinaculum, anomalous anconeus epitrochlearis muscle or masses in the
cubital tunnel. Signs of ulnar neuropathy may be present in more than
40% of throwing athletes with valgus instability or medial collateral
injury. The retinaculum about the cubital tunnel is absent in
approximately 10% of the population; this may cause subluxation of the
ulnar nerve and may be associated with symptoms of friction neuritis.
The nerve may sublux anterior to the medial epicondyle or remain
posterior and lateral to the epicondylar groove.
“Electrodiagnostic studies are often unable to demonstrate injury to
the ulnar nerve at the elbow. MRI enables one to determine the course
and identification of the potential sources of ulnar nerve
compression. MR features of ulnar neuropathy include nerve
displacement, focal or fusiform nerve enlargement and increased signal
intensity. The normal nerve is normally of intermediate signal on T2
weighted images, isointense or slightly higher in signal than muscle.”
(Have you ever had an MRI?)
One aspect of your question caught my eye. You mentioned that they
symptoms did not appear until 1998, after a period of inactivity
following a shoulder injury. Since both arms are affected, you see no
correlation between the one shoulder and both arms. This leads me to
think that something happened posturally to bring on these symptoms of
ulnar nerve pain. First of all, do you know for sure the nerve is
actually jumping out of the groove, or does it just feel that way?
Either way, there are some other avenues I would suggest you pursue:
Postural postural therapy for:
Poor scapular stability
Poor head and cervical alignment
Possibility of thoracic outlet syndrome
Possibility of cervical disk disease (only because I have seen it
mentioned in conjunction with ulnar nerve pain in several of the
articles)
An interesting article titled “Thoracic Outlet Syndrome: Fact or
Fiction?” by Christopher J. Centeno, MD. Spinal Injury Foundation at
http://www.whiplash101.com/thoracic_outlet_syndrome.htm is worth
reading. It has some interesting correlations between ulnar
entrapment, postural problems, cervical misalignment and overall
misdiagnosis.
“The diagnosis of TOS first shows up in the medical literature in the
1960’s. The syndrome gets its name from a constellation of symptoms
that all originate from compression of an area where the shoulder
meets the rib cage, dubbed the “Thoracic Outlet”. This area is in the
front of the neck, between the shoulder and the chest, under the
collarbone and above the ribs. If you think of this area as a house,
the floor would be the upper rib cage, the walls would be the scalene
muscles, and the roof would be the collarbone or clavicle. Since
major nerves and vascular structures pass through this space on their
way to the upper extremity, any compression can cause weakness,
numbness, and vascular changes in the upper extremity.”
“The most common
sub-type is Myogenic TOS. This is irritation and or compression of
the nerves and vessels that pass through this area. Since there is no
arterial blockage, this is not a surgical emergency, or usually even a
surgical problem. Patients frequently complain of numbness, tingling,
burning, or just pain usually in the two small fingers of the hand.
Complaints of weakness are not uncommon.”
“TOS can take many months to develop. A good example is a rock in
the shoe. If you place a rock in your shoe and leave it there for a
month, you’ll adapt your walking and gait around the pain. After
awhile, you’ll likely develop back pain from walking with a limp. A
similar set of events can occur to produce TOS. Neck and/or shoulder
pain frequently lead to changes in posture that can cause TOS. It’s
because of this phenomenon that there can be several month’s delay
between the onset of neck pain and TOS symptoms.”
“Exam is where most practitioners miss the diagnosis. The problem
seems to be due to a “compartmentalization” of the body by
musculoskeletal specialists. Most MD and DO physicians view the body
as disconnected areas. A common problem is the axial and peripheral
mindset. For example, many doctors without significant soft-tissue
training will limit their exam to the areas of complaint. Since many
patients complain of hand symptoms, the exam is often focused from the
elbow down. This poses a problem in rendering a correct diagnosis,
since the cause in the shoulder and thorax, not in the hand. Because
of this over focused exam strategy, the diagnoses of carpal tunnel
syndrome or **ulnar entrapment at the elbow** are frequently made
in error.”
Another reason to look at cervical problems or thoracic outlet
syndrome
From the article “Evaluation of Overuse Elbow Injuries.” American
Family Physician (2/1/2000) at
http://www.aafp.org/afp/20000201/691.html :
“Ulnar Nerve Entrapment. The presenting symptom of ulnar nerve
entrapment is medial elbow pain, but the disorder is also
characterized by distal paresthesias along the ulnar aspect of the
forearm and into the ring and little fingers (fourth and fifth
digits). The patient may complain of a weak grip, hand fatigue and
clumsiness. Ulnar nerve entrapment often occurs in throwing sports, as
well as racquet sports, weight lifting and skiing.”
“Tenderness or a positive Tinel's sign is present over the ulnar
nerve within the groove of the medial epicondyle. Other possible
physical findings include hypothenar atrophy and index pinch weakness.
“Electrodiagnostic tests may be positive, but false-negative test
results are common. Radiographs are often normal but may show
olecranon hypertrophy, osteophytes, medial calcifications or loose
bodies.”
“The ulnar nerve can also be compressed at the wrist (Guyon's
canal).**** Similar symptoms can be caused by cervical radiculopathy
and thoracic outlet syndrome.**** Attention to these related areas is
necessary to make the correct diagnosis.”
The following article, though at first might seem totally unrelated
to your problem, because it deals with repetitive stress injuries at
work (primarily computer work), has a wealth of information that might
help orient you in the direction of postural misalignment, nerve
impingment, and your resulting condition. I have excerpted a few
highlights from Repetitive Strain and Computer Professionals: A New
View,” by Jack Bellis and Suparna Damany. Excerpted from the book,
“It’s not Carpal Tunnel Syndrome (1999) at
http://www.rsiprogram.com/article.doc
The temptation in traditional diagnosis is to find one of the
individual problems described in our scenario, such as tenosynovitis,
and fix it by itself. But there’s more than enough evidence in the
literature to demonstrate that most sufferers don’t have just one of
these problems. The “syndromes” that are alluded to earlier are often
presented in the medical community as causes, but in our view they are
all results. And you almost always have symptoms from several of them.
This is confirmed by the following diagnosis of one particular, very
severe RSI patient, by Dr. E. Pascarelli, a pioneer in RSI theory. He
diagnosed her with:“Neuro-vascular thoracic outlet syndrome,
RSI/myofascial pain, lateral and medial epicondylitis, postural
mis-alignment, finger, hand, wrist and arm tendonitis.” Contrast this
with other doctors who diagnosed the patient with lupus and rheumatoid
arthritis!
Therapy:
“Eliminate trigger points that are entrapping nerves with vigorous,
localized massage. In normal activity, you won’t even notice these
spots, but when pressed, they will feel just like a splinter does—a
small but intense irritation. Although a therapist will probably be
most effective treating these, you may be able to treat them yourself
by pinching the spot, and while holding it, performing the type of
movement that the muscle would ordinarily cause. ****It took a
therapist 21 sessions (two a week, 45 minutes each) to zero-in on and
break through the fibrous tissue on my ulnar nerve at the elbow. The
surgeon who operated on my arm never once probed to look for this
spot.****
“To counteract nerve entrapment, perform motion exercises called
“glides,” in which you move your arm from one position to another,
without any force or resistance, to put a nerve or tendon through its
maximum range of motion.”
Read the entire article, and the section on questionable therapies
at the end.
I know I have not given you any definitive answers, which would be
impossible for me to do. However, I hope I have given you some
credible references which prove that your condition does, in fact,
exist in the medical literature. I also encourage you to look more
into some alternative therapies, specifically postural alignment and
trigger point therapy.
Keep searching. Be diligent. Try any alternatives you can think of.
However, I truly believe that the fact that this disorder showed up in
both arms after inactivity points to a postural or cervical
misalignment. With that said, I repeat, I am not a doctor.
umiat-ga
Search strategy on google
displaced ulnar nerve
+posture +Ulnar nerve +irritation
+displacement +ulnar nerve +from groove |
