New York State Medical Treatment Guidelines for Ulnar Neuropathies in workers compensation patients

The guidelines you see here were crafted by the New York State workers’ compensation board. They aim to lend a helping hand to physicians, podiatrists, and other healthcare professionals when it comes to providing the right treatment for Ulnar Neuropathies at the Elbow, which includes Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome.

These guidelines from the Workers Compensation Board are designed to be a supportive resource for healthcare professionals. They offer insights to aid in decision-making about the most suitable level of care for patients dealing with Ulnar Neuropathies.

It’s crucial to note that these guidelines aren’t a replacement for the wisdom of healthcare providers gained through clinical experience. The ultimate decision about care should always be a collaborative one, made by the patient in consultation with their healthcare provider.

Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

While nerves can get trapped anywhere along their length, the ulnar nerve at the elbow tends to be trapped most often in two specific spots. First, it gets entrapped in the condylar groove, and the second entrapment occurs in the actual anatomical cubital tunnel just distal to the elbow joint. As this tunnel begins forming, the ulnar nerve starts passing beneath the aponeurosis.

To identify the issue, a thorough nerve conduction investigation is necessary, involving stimulation both above and below the elbow. The American Academy of Electrodiagnostic Medicine suggests the “inching technique,” a logical approach for treatment, as it can pinpoint where the nerve conduction velocity is reduced and help determine the exact location of entrapment.

Despite its logical basis for treatment, the “inching technique” has not been extensively explored in high-quality interventional studies. In theory, simple decompression could be a potential cure for cubital tunnel syndrome. However, this decompression method, also known as “in situ,” is expected to be less effective in treating ulnar neuropathies in the condylar groove.

Currently, there is a lack of reliable studies, excluding surgical trials, to guide the treatment of ulnar neuropathies, and credible evidence supporting the benefits of available treatments is limited.

Initial Management of Ulnar Neuropathies at the Elbow; Involving Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

The first steps in care involve identifying potential factors that can be modified. This includes avoiding putting pressure on the elbow or nerve and being mindful of hyperextending the elbow during sleep, work, or leisure activities (refer to the elbow splinting section below).

Sleep Position for Elbows suggests teaching patients to sleep with their elbows extended rather than flexed.

Elbow Alignment at Work or During Hobbies advises against maintaining hyperflexed (>90o) elbow positions at work or during leisure activities.

Diagnostic Criteria for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

When assessing ulnar neuropathy at the elbow, it’s crucial to consider potential alternative diagnoses, including ulnar neuropathy at the wrist, C8 cervical radiculopathies, and other neurological entrapments like thoracic outlet syndrome, diabetic neuropathy, alcohol-induced neuropathy, systemic neuropathies, stroke, cerebrovascular events, and tumors of the central nervous system.

By conducting a comprehensive history, physical examination, or targeted testing, most other causes can be ruled out or their likelihood minimized. Some cases, as reported, may lack a clear cause.

Patients presumed to have ulnar neuropathy at the elbow typically experience: 1) tingling or numbness in the distribution of the ulnar nerve, often affecting the small finger and ulnar half of the ring finger; and 2) symptoms that are frequently triggered at night or with prolonged elbow flexion.

For individuals with an electrodiagnostic study (EDS) interpreted as consistent with ulnar neuropathy at the elbow, both of the symptoms mentioned earlier are expected for a provisional diagnosis. To diagnose cubital tunnel syndrome, it is essential to use the inching technique to identify the anomaly in the cubital tunnel, as opposed to the condylar groove or “funny bone.”

Special Studies and Diagnostic and Treatment Considerations for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Employing Electromyography to Diagnose Subacute or Chronic Peripheral Nerve Entrapments is a suggested approach for identifying chronic or subacute peripheral nerve entrapments, including radial, ulnar, and median neuropathies.

Indications – This is particularly recommended for patients experiencing acute or persistent paresthesias, with or without pain, especially in cases where the diagnosis is unclear. Individuals with peripheral neuropathies in the elbow region should typically undergo the inching method to pinpoint the entrapment, aiding in clinical care, along with segmental analysis (e.g., above vs. below elbow conduction).

According to reports, most of these individuals initially require non-operative care and might not need these tests.

Employing Electromyography for Diagnosis and Pre-Operative Assessment of Peripheral Nerve Entrapments is recommended to assist patients without a definite diagnosis in obtaining one. Electromyography serves as one of two ways to independently confirm a diagnosis before opting for surgical release.

Using Electromyography for the Initial Evaluation of Patients Suspected of Having a Peripheral Nerve Entrapment is recommended for the majority of patients’ initial evaluations because it doesn’t alter how the problem is managed, and other interventions are believed to be effective.

Ultrasound and MRI for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Assessing the ulnar nerve through MRI and ultrasound has been explored.

However, Diagnostic Ultrasound and MRI for the Evaluation and Diagnosis of Ulnar Neuropathies at the Elbow are not recommended for assessing and identifying ulnar neuropathies at the elbow.

Medications for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

First-Line Treatments: Ibuprofen, naproxen, or other NSAIDs from an earlier generation are recommended as the initial choice for most patients. If NSAIDs are not suitable, acetaminophen (or paracetamol) may serve as an alternative, although research suggests it is slightly less effective than NSAIDs.

Evidence indicates that NSAIDs are safer and equally effective in managing pain compared to opioids like tramadol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are suggested for acute, subacute, chronic, or post-operative Ulnar Neuropathies.

Recommendations:

• Initially, try over-the-counter (OTC) medications to assess their effectiveness.
• For patients who underwent surgical release of ulnar neuropathy, initiate treatment two to six weeks post-procedure.

Usage: For many patients, using NSAIDs as needed may be appropriate.

Discontinuation Criteria: Stop NSAIDs when elbow pain disappears, if they prove ineffective, or if adverse effects necessitate discontinuation.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding: Combining misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors is recommended for individuals at a high risk of gastrointestinal bleeding due to NSAID use.

Recommendations: Consider cytoprotective drugs for high-risk patients with indications for NSAIDs, particularly for prolonged treatment. Those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers are at an elevated risk.

Usage: Follow dosage recommendations from the manufacturer, as there are generally no significant differences in effectiveness in preventing gastrointestinal bleeding.

Discontinuation Criteria: Discontinue if there is intolerance, the onset of side effects, or upon completion of the prescribed course.

NSAIDs for Patients Prone to Cardiovascular Side Effects: It is recommended to use NSAIDs for patients at risk of cardiovascular adverse effects. Acetaminophen or aspirin are the preferred first-line treatments due to their safer cardiovascular profiles. Non-selective NSAIDs are employed as needed. When administering low-dose aspirin for cardiovascular disease prevention, it is preferable to opt for non-selective NSAIDs over COX-2-specific medications to mitigate the risk of conflicting effects. Administer the NSAID at least 30 minutes after or eight hours before aspirin to avoid interference.

Acetaminophen for Alleviating Elbow Discomfort: Acetaminophen is recommended for managing elbow pain, particularly in patients with contraindications to NSAIDs.

Usage:

• Applicable to all patients with acute, subacute, chronic, and post-operative elbow pain.
• Use in accordance with the manufacturer’s recommendations, keeping the daily intake below four gm to avoid liver toxicity.

Discontinuation Criteria: Cease usage when pain subsides, side effects emerge, or intolerance is observed.

Opioids for Ulnar Neuropathies at the Elbow: Occasionally, opioids have been utilized by patients with ulnar neuropathies at the elbow to alleviate pain, typically for a brief period following surgery.

Routine Opioid Use for Acute, Subacute, or Chronic Ulnar Neuropathies: It is not advisable to routinely use opioids for the treatment of acute, subacute, or chronic ulnar neuropathies at the elbow.

Rationale for Recommendations: There is a lack of substantial studies demonstrating the effectiveness of opioids in treating ulnar neuropathies. Opioids carry serious side effects, including low tolerance, bloating, sleepiness, impaired judgment, memory loss, and a risk of dependence, reported in 35% or more of patients.

Precautions: Patients should consult their doctors before accepting an opioid prescription, being made aware of potential adverse effects and advised against operating machinery or driving. Opioids do not exhibit superior efficacy to less risky analgesics for treating musculoskeletal complaints. They should be reserved for instances of severe pain or for a short recovery period (no longer than a week) post-surgery, and are generally discouraged for ongoing treatment of ulnar nerve pain.

Using Opioids for Managing Specific Postoperative Ulnar Neuropathy Patients: Recommendation is made for the limited application of opioids, lasting no more than a week, for a specific subset of patients recently subjected to surgery for ulnar neuropathy, particularly those facing challenges.

Criteria:

• Select patients recently undergoing ulnar nerve procedures, usually transpositions, experiencing severe pain (especially when NSAIDs fail to provide relief) or encountering complications.
• Administer for a brief period, spanning a few days to weeks, primarily during nighttime to aid postoperative sleep. Extended usage may be warranted for individuals with more severe concerns.

Discontinuation Guidelines: Halt usage upon achieving pain relief, noting adverse effects or intolerance.

Reasoning: Postoperative opioid use, in addition to NSAIDs, is often required for a few days, especially in transposition patients with larger wounds. Some individuals may necessitate prolonged use. Opioid application is suggested for short-term, selective utilization post-surgery, mainly at night to facilitate sleep.

Glucocorticosteroids (Oral or Injections) for Treating Acute, Subacute, or Chronic Ulnar Neuropathies at the Elbow: Recommendation is made for the use of glucocorticosteroids in oral or injection form to address acute, subacute, or chronic ulnar neuropathies at the elbow. Differentiation is emphasized, as steroid injection into the ulnar nerve within the cubital tunnel may be detrimental.

Vitamins, Including Pyridoxine, for Managing Acute, Subacute, or Chronic Ulnar Neuropathies: It is advised to utilize vitamins, including pyridoxine, for routine care of acute, subacute, or chronic ulnar neuropathies in individuals without vitamin deficiencies.

Lidocaine Patches for Treating Acute, Subacute, or Chronic Ulnar Neuropathies: Recommendation is made for the application of lidocaine patches to address chronic, acute, or subacute ulnar neuropathies causing pain.

Ketamine for Managing Acute, Subacute, or Chronic Ulnar Neuropathies: Ketamine is recommended for managing painful acute, subacute, or long-term ulnar neuropathies.

Treatments for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Rehabilitation: Devices / Therapy

After a work-related injury, supervised formal therapy (rehab) should focus on restoring the functional abilities required for daily and work responsibilities. The primary aim is to enable the patient to return to work, striving to restore the injured worker to their pre-injury status to the extent feasible.

Active therapy involves the patient actively participating in specific activities or tasks, while passive therapy involves modalities administered by a therapist, with no effort required from the patient. Passive interventions are often used to expedite an active therapy program and concurrently achieve objective functional gains. Priority should be given to active initiatives over passive interventions.

Encouraging patients to continue both active and passive therapies at home serves as an additional step in the healing process to maintain the improvements.

Assistive devices may be incorporated into the rehabilitation strategy to facilitate functional gains.

Activity Modification and Exercise

Various exercise regimens, commonly involving tendon-gliding and nerve-gliding activities, have been employed in treating patients with ulnar neuropathies at the elbow. Interventions are also provided to address changes in activities of daily living (ADL) and instrumental activities of daily living (IADL) performance.

Devices for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Magnets for Managing Pain From Acute, Subacute, or Chronic Ulnar Neuropathies

Recommendation is made for the use of magnets to manage pain associated with acute, subacute, or persistent ulnar neuropathies.

Nocturnal Elbow Splinting for Treatment of Acute, Subacute, or Chronic Ulnar Neuropathies

Recommendation is given for the utilization of nocturnal elbow splinting to address pain associated with acute, subacute, or persistent ulnar neuropathies.

Criteria:

• Applicable for condylar groove or cubital tunnel symptoms in the elbow indicative of ulnar neuropathy.
• Advised use of elbow splints or braces during sleep (within the range of 45-70 degrees).
• Splints should be reevaluated and potentially replaced if no improvement is observed after two weeks of treatment, ensuring proper usage and fit. Discontinuation is advised if there is no improvement, prompting a reevaluation of the original diagnosis.

Therapeutic Exercise – Physical / Occupational Therapy for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Engaging in Physical or Occupational Therapy for Acute, Subacute, Chronic, or Postoperative Ulnar Neuropathy is recommended to address postoperative, chronic, subacute, or acute ulnar neuropathy.

• The total number of therapy sessions may vary based on individual needs, ranging from two to three for minor functional deficits to 12 to 15 for more severe deficits.
• Continued objective functional progress determines the frequency and duration of therapy.
• Individuals with persistent functional impairments may require more than 12 to 15 sessions to achieve specific functional goals.
• The inclusion of a home exercise regimen as part of the rehabilitation strategy is essential, complementing the therapy.

Passive Therapies for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Low-Level Laser Therapy for Acute, Subacute, or Chronic Ulnar Neuropathies is recommended to manage acute, subacute, or persistent ulnar neuropathies.

Ultrasound for Acute, Subacute, or Chronic Ulnar Neuropathies is advised for the treatment of ulnar neuropathies, whether acute, subacute, or chronic.

• Indications include ulnar neuropathies with noticeable symptoms requiring medical attention, and patients with an inadequate response may benefit from nocturnal splints.
• Discontinuation is warranted upon resolution, lack of measurable improvement, or intolerance.

Other Approaches for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Acupuncture, Biofeedback, Manipulation and Mobilization, Massage, Soft Tissue Massage, Iontophoresis, and Phonophoresis are recommended for the treatment of acute, subacute, or chronic elbow ulnar neuropathies.

Surgical Interventions for Ulnar Neuropathies at the Elbow; Including Condylar Groove Associated Ulnar Neuropathy and Cubital Tunnel Syndrome

Ulnar Nerve Operations (Simple Release, Transpositions, Medial Epicondylectomy) offer various surgical approaches to address ulnar neuropathy at the elbow. Surgical referral becomes necessary for patients displaying significant warning signs or failing to improve with non-surgical treatments.

• Surgical considerations are contingent on the established diagnosis of symptoms.
• Counselling is essential, providing information on potential outcomes, risks, benefits, and setting realistic expectations for surgery.
• Pre-surgery discussions should cover post-operative pain management and adherence to the rehabilitation exercise program.
• To prevent adhesive capsulitis (frozen shoulder), postoperative range-of-motion exercises should target the elbow, wrist, and shoulder.