Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Neuropathy of Ulnar Nerve (Entrapment)


Related Terms

  • Cubital Tunnel Syndrome
  • Handle-bar Palsy
  • Tardy Ulnar Palsy
  • Ulnar Neuritis
  • Ulnar Neuropathy
  • Ulnar Tunnel Syndrome

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Comorbid Conditions

Factors Influencing Duration

The inability to modify job requirements will greatly affect disability, as will severity of symptoms, whether the dominant or nondominant arm is involved, response to conservative treatment, and subsequent need for surgery. Compliance with the rehabilitation exercise program will substantially affect duration.

Medical Codes

ICD-9-CM:
354.2 - Lesion of Ulnar Nerve; Cubital Tunnel Syndrome; Tardy Ulnar Nerve Palsy

Overview

© Reed Group
The ulnar nerve is responsible for the function of many muscles in the forearm and hand and for sensation in the ring and little (small) fingers. The term "neuropathy" refers to impairment of a nerve, in this case, the ulnar nerve, when it becomes constricted (entrapped) or compressed along its route from the neck to the hand. The elbow is the most common site of ulnar nerve compression (Verheyden). Ulnar neuropathy at the wrist is less common.

The ulnar nerve must travel through a groove and tunnel at the elbow and a canal in the wrist, which are potential sites for entrapment and irritation. The nerve can become constricted (entrapped) at the elbow or wrist by direct pressure over the nerve groove/tunnel/canal. Although many ulnar neuropathies develop slowly and are associated with physical activity, they can also result from acute trauma and anomalous muscles (Fahrer; Failla; Vance). Fractures or dislocations of the elbow or wrist may cause entrapment of the nerve, especially at the elbow where the nerve may become dislodged from the canal.

When irritation of the ulnar nerve, known as ulnar neuritis or ulnar neuropathy, occurs near the elbow, it is known as ulnar tunnel syndrome or cubital tunnel syndrome. Exact causes for ulnar nerve entrapment at the elbow are unknown. Commonly cited causes include direct pressure on the nerve (e.g., resting of the proximal elbow or forearm on, or against, a surface) and a persistently flexed elbow posture greater than 90°. In the elbow, the bony olecranon (epicondylar) groove holds the ulnar nerve and its accompanying blood vessels on the back and inside (posteromedial border) of the elbow; this is the most common site for ulnar nerve entrapment. In addition, a congenitally shallow groove may allow the ulnar nerve to slide out of the groove (subluxation) when the elbow is bent (flexed), causing irritation and swelling (neuritis, neuropathy). The continuation of the olecranon groove at the posteromedial elbow is the cubital tunnel, which is covered by flexor muscles and a tight band of fascia; it is also compressed when the elbow is bent. Symptoms are often associated with driving, sleeping with the elbow bent, typing, lifting weights, playing tennis, or pitching a baseball (Yamaguchi; Pechan; Apfelberg). It is unclear if repetitive motion contributes to causation (Melhorn).

Entrapment also may occur following muscular hypertrophy, elbow fracture, and scar tissue or bone spur formation. If a fracture of the distal humerus (near the elbow) heals with a valgus deformity, this places a chronic stretch on the nerve that may result in ulnar neuropathy years later. This late development of ulnar neuropathy related to fracture deformity is called tardy ulnar palsy.

When irritation of the ulnar nerve occurs at the wrist level, it is known as Guyon's canal syndrome, or ulnar nerve entrapment at the wrist. In the wrist, the ulnar nerve and artery pass through a small canal (Guyon's canal). A direct blow over this area, on the palm, or near the wrist can cause inflammation and compression of the nerve. Compression and inflammation also can result from repetitive trauma such as using a hammer. A cyst (ganglion) or an aneurysm in the ulnar artery in the canal also can put pressure on the nerve.

Incidence and Prevalence: Cubital tunnel syndrome is the second most common compressive neuropathy, after carpal tunnel syndrome (Verheyden). One study found that in 16.2% of the general population, the ulnar nerve slipped out (subluxation) of its olecranon groove when the elbow was flexed (Verheyden). In another study, in 15% of the population, the nerve spontaneously slips out of the cubital tunnel at the elbow (Hanna).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Men experience cubital tunnel syndrome 3 to 8 times more often than women (Verheyden). Occupational risk factors for ulnar nerve elbow entrapment have been reviewed. Although symptoms may be experienced with force and repetition, force and posture, vibration, repetitive work, awkward postures, and keyboard activities, the science currently finds "insufficient evidence" to support occupational risk. Individual risk factors include age, increasing BMI, and female gender. For more information, refer to "Disease and Injury Causation," page 181.

Source: Medical Disability Advisor



Diagnosis

History: Individuals with ulnar neuropathy at the elbow may complain of numbness, tingling, or pain in ulnar side of the hand (ring and little finger). These symptoms (numbness or paresthesias) may at first be intermittent and then increase with activity or use of the elbow (often flexion). As the neuropathy progresses, grip weakness and loss of coordination become apparent. The pain may awaken the individual at night.

In the wrist, ulnar neuropathy leads to some loss of sensation and a decrease in grip and pinch strength. The muscle in the palm along the ulnar hand (hypothenar eminence) and the intrinsic muscles of the hand may be atrophied. With permanent loss, the fingers may be held like a claw (claw hand).

Physical exam: The exam focuses on sensory changes, joint range of motion, and muscle strength. The ulnar nerve may be felt at the elbow and found to sublux over the medial epicondyle when the elbow is flexed. Decreased pinch strength may be seen when the individual attempts to hold a piece of paper between the extended thumb and a flat palm; with ulnar neuropathy, weakness is demonstrated by compensatory flexion of the thumb in an effort to hold onto the paper (Froment's sign). Holding the elbow in sustained full flexion with the wrist in a neutral position also tests the nerve. This test, similar to Phalen's test for carpal tunnel syndrome, is positive for elbow neuropathy if tingling in the ring and small finger begins in less than 60 seconds.

The individual may note tingling along the nerve when the physician taps the nerve at the wrist with a percussion hammer (often described as Tinel's sign) or when tapping at the elbow; however, this sign is not by itself diagnostic and is best used merely to confirm reproduction of the distribution of the individual's symptoms. Changes in sensation in the ring and little fingers will be noted, along with atrophy of the ulnar edge of the hand and the intrinsic muscles. Deformity of the hand comes in late stages of the syndrome and is more common with major nerve injury (e.g., nerve laceration) than with entrapment.

Tests: Electromyographic (EMG) and nerve conduction studies establish nerve function. At the elbow, EMG testing should be done with the elbow flexed between 70° and 90° to improve accuracy. Electrodiagnostic testing is often negative (Eversmann; Mackinnon). X-rays and CT scans may be done to determine if fractures or anatomical abnormalities are contributing to nerve compression. MRI of the wrist may demonstrate a ganglion cyst or an ulnar artery aneurysm compressing the nerve. Advances in the technical capability and accuracy of ultrasonography have led to its use in detecting thrombosis of the ulnar artery and other abnormalities.

Source: Medical Disability Advisor



Treatment

Treatment begins with rest and avoiding or limiting aggravating movements and positions, such as leaning on elbows, or engaging in prolonged or repetitive flexion or throwing. Analgesics and other medications may be prescribed to help alleviate pain and encourage restful sleep (Vallarino). Ulnar neuropathy at the elbow and wrist is difficult to treat with splinting, but may respond to cushioning or padding the area. Splinting the elbow in extension or mild flexion at bedtime may prevent full elbow flexion for sustained periods, resulting in marked symptom improvement (Pauda). Local injections of corticosteroids may be helpful in decreasing inflammation of the nerve.

If conservative treatment is not successful and/or the neuropathy is documented on nerve conduction testing, or if the symptoms and exam findings progressively worsen, then enlarging the tunnel (surgical decompression) of the elbow or wrist may be recommended. In cases of entrapment at the elbow, some surgeons may choose to reposition the ulnar nerve (ulnar nerve transposition) to prevent it from subluxating and/or to relieve direct pressure on the nerve when the elbow rests on a hard surface. Other surgeons may choose to remove the bony medial epicondyle or simply to release the tight fascial structures around the nerve. In cases involving the wrist, the canal may be enlarged to relieve pressure on the nerve by cutting the overlying ligament. Currently simple decompression provides a better outcome with less risk of complications (Nabhan).

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Ulnar Nerve Entrapment Elbow (including Cubital Tunnel Syndrome)
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Early recognition of the neuropathy, along with either medical or surgical treatment (decompression and/or transposition), is important to reduce weakness and changes in sensation, allowing for return to normal function. The highest recurrence rate of cubital tunnel syndrome is in the non-operatively treated patients (Mowlavi).

Decompression or release of the tight band entrapping the ulnar nerve at the elbow provides a good to excellent outcome if individuals are treated promptly; a much smaller percentage of those undergoing surgery for chronic ulnar nerve compression experience improvement in symptoms. A comprehensive review concluded that with more advanced cubital tunnel syndrome, simple decompression was unlikely to be successful. In severely affected patients, all types of surgical treatment produced similarly poor results (Mowlavi).

If, at the time of surgery, the ulnar nerve is unstable in the ulnar groove or tunnel during range of motion, ulnar nerve transposition may help relieve pressure on the nerve and prevent it from sliding over the medial epicondyle; however, this procedure often increases the area of skin numbness or hypersensitivity at the elbow over the surgical site. The procedure has fair to good results in most individuals, although reported positive outcomes are not as significant in individuals with abnormal preoperative nerve conduction studies or in those with a work-related injury.

Source: Medical Disability Advisor



Rehabilitation

For cubital tunnel syndrome and Guyon's canal syndrome the conservative (nonoperative) treatment goals are quite similar and are indicated for mild ulnar neuropathy. These goals include rest with the application of protective splinting, use of modalities such as heat and cold to calm pain and to reduce swelling, and education concerning the individual's posture to avoid external nerve compression or repeated friction.

The appropriate rehabilitation specialist should review the work environment, as well as the method of performing activity of daily living tasks and sleep positions, for habits that may aggravate the condition, including postural alignment, use of tools, repetitive activities, and other patterns of movement. Patients should use braces, splints, and/or elbow padding to avoid over-flexing the elbow or direct pressure on the ulnar nerve. An ergonomic assessment may be beneficial for individuals with an ulnar nerve neuropathy (Weiss), and individuals are instructed to maintain an open elbow position not to exceed more than 30 degrees of flexion during daily activities and at night.

During rehabilitation, the individual may see a rehabilitation specialist 2 to 3 times a week initially. However, in most cases, individuals progress quickly to a home exercise program. The initial goal is to reduce pain and edema through range of motion exercises, activity modification, and ergonomic changes. The therapist teaches the individual how to move and position the involved structures without provoking nerve irritation. The individual implements these activities at home (Nathan). Once symptoms are reduced and as the stage of healing allows, the therapist teaches strengthening exercises with an emphasis on strengthening the forearm pronators and elbow flexors (Weiss). All activities, exercises, and postures that reproduce symptoms must be modified (Aiello; Blackmore).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistNeuropathy of Ulnar Nerve (Entrapment)
Physical or Occupational TherapistUp to 4 visits within 12 weeks
Surgical
SpecialistNeuropathy of Ulnar Nerve (Entrapment)
Physical or Occupational TherapistUp to 6 visits within 12 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Failure to treat the neuropathy may result in permanent nerve damage, loss of muscle mass, and loss of function of the hand and wrist. Chronic hand pain can progress to regional pain syndrome. Depression may result in those individuals whose prior occupational and recreational activities are interrupted indefinitely.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Modification of activities is the best approach to the treatment of musculoskeletal pain and wrist or elbow symptoms of ulnar nerve entrapment that are associated with activities at home and work.

Return to work is dependent on three conditions: risk, capacity, and tolerance. Risk is the likelihood of recurrence of the condition from performing activities, capacity is the actual ability to perform activities, and tolerance is the individual's willingness to endure some discomfort in the healing phase. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function (Melhorn).
Restrictions should address sustained posturing with the elbow in flexion of greater than 90 degrees, highly repetitive elbow flexion, and repetitive contusion of or sustained pressure on the nerve.
Ergonomic evaluation of the work area is helpful to identify possible factors that may contribute to symptoms such as positioning keyboards too high, sitting too close to the keyboard or steering wheel of a car, or holding a telephone with the elbow in sustained flexion of 90° or more for repeated or extended periods of time. Addressing these factors may allow an earlier return to work, at least in a limited capacity. Some individuals may not be able to return to aggravating activities such as constant hammering.

For more information, refer to "Work Ability and Return to Work," pages 194-195.

Risk: If nerve function is documented at multiple office visits, and if it is clearly worsening with continued work activity and subsequently improves with temporary work restrictions, it is reasonable to conclude that this work activity is a risk to this patient’s ulnar nerve. Either permanent work restrictions or surgical treatment would be indicated. Generally the weight lifted at work is not a problem.

Capacity: Capacity is dependent on the function of the nerve and muscles. As the condition becomes chronic, permanent nerve damage may occur which results in a reduction of muscle mass and therefore grip and pinch strength.

Tolerance: Tolerance for symptoms such as pain and paresthesia is the most frequent problem. But if documented function loss is occurring, surgical decompression is recommend to maintain function.

Accommodations: Accommodations are usually provided to limited prolonged elbow flexion, direct pressure on the nerve elbow or wrist.

Source: Medical Disability Advisor



Maximum Medical Improvement

8 to 12 weeks post surgery

Continued improvement is possible over 18 months, but the amount of improvement is limited.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual frequently perform activities that require repeated bending of the elbow to greater than 90° of flexion, such as driving, sleeping, typing, lifting weights, or pitching a baseball?
  • Has individual experienced recent trauma to the wrist or palm?
  • Has there been a recent or past fracture or dislocation of the elbow or wrist?
  • Does individual perform activities that cause repetitive trauma, such as using a hammer or using the ulnar border of the hand as a tool to apply pressure?
  • Does individual complain of numbness and tingling or pain in the ring and small fingers?
  • Do symptoms worsen with increased activity or use of the elbow?
  • Does individual complain of weakness and loss of coordination in the arm or a decrease in grip strength?
  • Does pain awaken the individual from sleep?
  • Were electromyographic and nerve conduction studies done? Were the electrodiagnostic studies consistent with ulnar neuropathy?
  • Were x-rays or CT scans done to determine if anatomical abnormalities are contributing to nerve compression?
  • Was an MRI of the wrist done if ulnar neuropathy at the wrist was diagnosed?
  • Was ultrasonography performed to detect circulatory or other anatomical abnormalities?

Regarding treatment:

  • Were elbow and wrist splinted and cushioned or padded?
  • Was elbow flexion restricted?
  • Was the activity that caused pressure over the nerve stopped?
  • Were injections of corticosteroids required to decrease nerve inflammation?
  • Did splinting, restricting activity, and administering medication effectively resolve the neuropathy?
  • Is individual compliant with a rehabilitation program for stretching and gentle strengthening?
  • If symptoms worsened, did individual require surgical decompression of the nerve tunnel?
  • If elbow was affected, was ulnar nerve transposition necessary?
  • Did any postsurgical complications occur?

Regarding prognosis:

  • Was medical treatment sufficient to resolve the condition, or was surgical treatment necessary?
  • Did individual restrict activities and wear splints exactly as directed?
  • Was individual compliant with rehabilitation program?
  • Does post-treatment nerve pain interfere with individual's daily activities?
  • Has permanent nerve damage occurred, resulting in loss of function of the hand and wrist?
  • Is any treatment available to treat the nerve damage and/or restore hand and wrist function?

Source: Medical Disability Advisor



References

Cited

Aiello, B. "Ulnar Nerve Compression." Hand Rehabilitation: A Practical Guide. Eds. Gaylord L. Clark, et al. 2nd ed. New York: Churchill Livingstone, Inc., 1998.

Apfelberg, D. B., and S. J. Larson. "Dynamic Anatomy of the Ulnar Nerve at the Elbow." Plastic and Reconstructive Surgery 51 (1973): 79-81.

Blackmore, S. M. "Therapist's Management of Ulnar Nerve Neuropathy at the Elbow." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Eversmann, W. W. "Entrapment and Compression Neuropathies." Operative Hand Surgery. Eds. D. P. Green, et al. New York: Churchill Livingstone, Inc., 1988. 1423.

Fahrer, M., and P. J. Millroy. "Ulnar Nerve Compression Neuropathy Due to an Anomalous Abductor Digiti Minimi-clinical and Anatomic Study." Journal of Hand Surgery 6 (1981): 266-268.

Failla, J. M. "The Hypothenar Abductor Muscle: An Anomalous Intrinsic Muscle Compressing the Ulnar Nerve." Journal of Hand Surgery 21 (1996): 366-368.

Hanna, Amgad Saddik , et al. "Nerve Entrapment Syndromes." eMedicine. Eds. Michael G. Nosko, et al. 13 Jan. 2012. Medscape. 17 May 2013 <http://emedicine.medscape.com/article/249784-overview>.

Mackinnon, S. E., et al. "Histopathology of Compression of the Superficial Radial Nerve in the Forearm." Journal of Hand Surgery 11 (1986): 206-210.

Melhorn, J. M., and William Ackerman, eds. Guides to the Evaluation of Disease and Injury Causation. New York: American Medical Association, 2007.

Mowlavi, A. K., et al. "The Management of Cubital Tunnel Syndrome: A Meta-analysis of Clinical Studies." Plastic and Reconstructive Surgery 106 (2000): 327-334.

Nathan, P. A., R. C. Keniston, and K. D. Meadows. "Outcome Study of Ulnar Nerve Compression at the Elbow Treated with Simple Decompression and an Early Programme of Physical Therapy." Journal of Hand Surgery - British and European Volume 20 5 (1995): 628-637. National Center for Biotechnology Information. National Library of Medicine. 12 Oct. 2008 <PMID: 8543870>.

Pechan, J., and I. Julius. "The Pressure Measurement of the Ulnar Nerve: A Contribution to the Pathophysiology of the Cubital Tunnel Syndrome." Journal of Biomechanics 8 (1975): 75-79.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Talmage, J. B., J. M. Melhorn, and , eds. "Working with Common Upper Extremity Problems." A Physician's Guide to Return to Work. Chicago: AMA Press, 2005.

Vallarino, Ramon, and Francisco H. Santiago. "Ulnar Neuropathy (Wrist)." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Vance, R. M., and R. H. Gelberman. "Acute Ulnar Neuropathy with Fractures at the Wrist." Journal of Bone and Joint Surgery 60 (1978): 962-965.

Verheyden, James R., and Andrew K. Palmer. "Cubital Tunnel Syndrome." eMedicine. Eds. Mark D. Lazarus, et al. 8 Mar. 2013. Medscape. 17 May 2013 <http://emedicine.com/orthoped/topic479.htm>.

Weiss, Lyn D., et al., eds. "Chapter 23 - Neuropathy (Elbow)." Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Yamaguchi, K., et al. "Changes in Interstitial Pressure and Cross-sectional Area of the Cubital Tunnel and of the Ulnar Nerve with Flexion of the Elbow." Journal of Bone and Joint Surgery 80 (1998): 492-501.

Source: Medical Disability Advisor






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