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Ulnar neuropathy at the elbow with subluxation

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  • Ulnar neuropathy at the elbow with subluxation

    Hi all, (scroll down to bottom if want to get straight to question)

    My name is Rene. I am a practicing PM&R physician; an avid fan of BBM; and a passionate recreational lifter. Ever since I was a kid, I have had bilateral subluxing ulnar nerves (whenever there is resisted flexion/extension of the elbow) the nerve pops right out of the post-condylar groove. No big deal, just sounds funny on bench and presses. More back story: when I was about 13 yo (I am 30 yo now) I had a compression injury to my right ulnar nerve (fell onto a roller blade brake); never had deficits from it, never had it checked out. Only caveat on the right ulnar nerve: whenever I bump it into something now, it hurts like the dickens (like a tinel's on steroids). Anyhoo, throughout the latter half of residency, I have been having occasional paresthesias to the right small and ring finger (i.e. ulnar nerve distribution) with deep dips. Solution: don't go so deep. That worked for about 12 months. Then, this progressed to symptoms with bench and over head press. Now, at this point, the symptoms would only occur during the training session, and resolve in about 30 minutes. What did I do? Changed my approach to doing sets with lower rep ranges (thinking the less the nerve is exposed to subluxation, the better). This worked up until about 6 weeks ago. Now: I have symptoms of paresthesias with straight-armed exercises (like deadlifts), and I have had to back off of any exercises that require resisted elbow flexion/extension (even pin press/bench set to higher levels with less ROM cause symptoms), which really, really sucks.

    What do we have objectively:
    Ultrasound: fascicular changes in the post-condylar groove of the right ulnar nerve (i.e. the nerve looks honey-combed below the elbow and above the elbow, but at the elbow there is a coalesced, altered fascicular pattern in the post-condylar groove).

    NCS/EMG: evidence of motor slowing of the right ulnar nerve at/about the elbow. No evidence of axonal loss/denervation. No evidence of radiculopathy/plexopathy

    I am at a stand still here. I am bracing the arm at night, so it doesn't flex past 35 degrees (been doing so for about a year), and this prevents me waking up at night due to numbness, but the symptoms during the day still come. I have had no loss of strength or overt atrophy, just two episodes of "clumsiness" while I was doing EMGs (these also happened on heavy deadlift days). Short of splinting the arm for 24 hours a day for several weeks, I am not sure what else to do. In my patients, I normally send to ortho at this point for consideration of ulnar nerve transposition. I don't want to stop lifting. I don't want to progress into axonal loss if I ignore this. Sigh...

    QUESTION: does anyone have personal/client experience with this (ulnar neuropathy at the elbow with subluxation) and/or the surgery (ulnar nerve transposition)? What were the outcomes (I see this surgery done on older patients with severe disease, so my selection bias sees nothing but poor outcomes--the literature says otherwise)? Any pearls of wisdom?

    Thanks!

  • #2
    FYI my partner has the same symptoms but less severe, and would also be v interested in conservative mgmt options / surgical outcomes (she has yet to get a conduction study and is hesitant about surgery as being an ED reg it would impact her work).

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    • #3
      Rene,
      I'm sorry to hear you are dealing with this. I have seen a few instances of what you are describing in athletes. One of them was a minor league pitcher and did have good results from the surgery (he returned to AA pitching from AAA). He also had progressive motor weakness that ended up being the indication for the surgery. If one of your PTs or OTs has a hand held dynamometer I would run over and give that a check so you have an objective number of strength. Sometimes OTs have fancy ones that let you check individual grips types (for those reading there are more than standard and hook grip). If you are seeing any progressive motor weakness I would consider the surgery. Otherwise, I would attempt symptom management. As much as this could turn into a discussion between Mike and I regarding the efficacy of the intervention. Neural mobilizations can sometimes work to help with habituating symptoms. Full discloser, the evidence is limited and I certainly do not think we are eliciting any structural change but it can work as a form of graded exposure with which to let you tolerate more range and more time in that range. Here is a recent meta analysis related to their utility and it does slant more towards low back and neck pain.

      ​​​​​​https://www.jospt.org/doi/10.2519/jospt.2017.7117

      To circle back to the dynamometer statement. I have motor weakness in L3 distribution from a prior injury and it was a good lesson in what you can adapt to, even with a deficit. That being said, dynamometers are spectacular at giving you quantifiable numbers to work from. At one point I was a 50% quad deficit and still training/playing sports without symptoms and my squats, even though they were lower did not "feel" all that bad. This is a large muscle group so the difference is likely dramatic but even in the ulnar distribution if you can start putting a number on your grip strength, you can start working to increase it. Anecdotally, to your point regarding clumsiness, I would experience episodes of my leg "giving out" early on but it was rarely when I was walking with intention but more when I was just meandering. This would happen more often after a day of squats. It sounds pretty analogous to what you are reporting while performing EMG.

      Derek

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