Ulnar nerve entrapment occurs when the ulnar nerve is compressed. This usually occurs in two main areas: the elbow and wrist . Ulnar nerve entrapment at the elbow usually occurs in the cubital tunnel (cubital tunnel syndrome). Ulnar nerve neuropathy at the elbow is the second most common Compressive neuropathy (first and most common is the median nerve at the wrist).  Ulnar neuropathy occurs less frequently in the Guyon’s canal of the wrist (Guyon’s canal syndrome/ulnar tunnel syndrome).
Ulnar nerve entrapment at the elbow (cubital tunnel syndrome) and wrist (Guayonne’s tunnel syndrome) is due to repeated compression of the elbow or wrist (cyclist’s palsy) against the elbow or wrist and the long caused by time warping. It can also occur from trauma that swells fractures and blood vessels and bones pathological/abnormal.
Guyon’s tunnel syndrome occurs when the ulnar nerve becomes trapped between the hook of the hamate and the transverse carpal ligament. Guyon’s tube syndrome is considered an overuse injury, usually caused by direct pressure on the handlebars (i.e. bicycle handlebar weight lifting construction equipment), and is therefore sometimes referred to as “handlebar paralysis”. It can also be caused by excessive grip twisting or repetitive wrist and hand movements. Entrapment can also occur if the hand is bent for prolonged periods of time and the ulna is deviated.
The incidence of trauma-induced ulnar nerve compression is unknown; however, ulnar neuropathy has been documented after distal humeral fractures and up to 10% of elbow dislocations, and may also result from any complicated elbow or wrist trauma developed. 
Symptoms of ulnar nerve entrapment include tingling in fingers 4 and 5, weak grip, pain and sensitivity on the ulnar side of the forearm at the wrist, and atrophy of the hand muscles, fingers 4 and 5 (a sign of blessing).
Cubital tunnel syndrome can vary in severity:
Grade I: Mild symptoms including:
- Intermittent paresthesia
- Slight loss of dorsal and volar sensation on the medial side of the fifth and fourth fingers
- No motor changes
Class II: Moderate and persistent symptoms, including:
- Dorsal and volar hypoesthesia on the medial side of the fifth and fourth fingers
- Mild weakness of the muscles innervated by the ulnar nerve
- Early signs of muscular atrophy
Grade III: Severe symptoms including:
- There was marked loss of dorsal and volar sensation on the medial sides of the fifth and fourth fingers.
- severe functional and movement impairment
- Muscle atrophy of the hand intrinsics
- Possible number grabs for fourth and fifth digits (signs of blessings)
Symptoms of Gain’s duct syndrome include:
- Muscle atrophy – mainly hypothenar and interosseous muscles, sparing thenar group muscles:
- Weakened finger abduction and adduction (interossei)
- weakened adducted thumb
- Loss of sensation and pain that may involve the volar surface of the fifth finger and medial fourth finger and medial fourth finger and dorsal fifth finger There is no sensory loss.
- Ulnar claws may appear (sign of blessing)
Physical Therapy Examination
Guyon’s duct syndrome: It is important to rule out other diagnoses that may involve the elbow. Physical examination includes
- ROM of the wrist and digits
- MMT of the ulnar nerve muscles innervating the distal Gainian canal
- Sensory examination of the skin distribution of the ulnar nerve distal to Guyon’s canal
- Muscle wasting of intrinsic hand muscles
- Card test
- Froment’s Sign
- Tinnel sign on the Guyon Canal
- Ulnar nerve dynamics test (ULTT3) may exacerbate patient symptoms
Diagnostic tests for ulnar nerve entrapment
- Imaging of OA Bone Spurs or Bone Cysts
- Nerve Conduction Studies (EMG)
- Plain x-ray if fracture/dislocation is suspected
- Disability of the Arm, Shoulder, and Hand – a 30-item questionnaire designed to measure a patient’s physical function and symptoms
- Patient-Specific Functional Scale (PSFS) – Questionnaire to quantify activity limitations and measure patient functional outcomes
- DASH Outcome Measure – a questionnaire that measures patient functional capacity and symptom severity
- Upper Extremity Functionality Index (UEFI) – a 20-item questionnaire about difficulty performing activities throughout the day
- Impairment-Based Approaches Can be Used to Address Strength ROM Deficiencies and Achieve Functional Goals
- The source of the pain should be treated along with the injury.
- Reassess pain-producing functional tasks after treatment to determine effective treatment outcomes
- Administer a home exercise program designed to treat the same impairment and functional tasks
In a study by Svernlov and colleagues, three treatments were compared for patients with cubital tunnel syndrome.  All three groups had positive results, with the control group improving as much as the intervention group. 
- Splint Set Protocol – An elbow brace is worn nightly for three months, the brace prevents the elbow from flexing more than 45 degrees. 
- Neurogliding Protocol – Instruct patients to complete the neurogliding exercise twice daily in six different positions and hold for 30 seconds for three repetitions with 1 minute of rest between repetitions. Instruct the patient to complete these exercises until the next time Visits occur 1-2 weeks later. If asymptomatic at the next visit, the frequency of exercise is increased to 3 times a day for one minute per day for three months. 
- Control group protocol – control group received education only 
According to a case report by Coppieters and colleagues, 6 sessions of combined thoracic mobilization at the elbow and rib thrust manipulation and ulnar nerve slide/tension technique were associated with less elbow pain and significant improvement in neck scores A ten-month follow-up questionnaire.  The patient reported a two-month history of symptoms before starting physical therapy.  The protocol used in this study can be viewed by accessing the link in the case studies section below.
Gaine’s tunnel syndrome and other ulnar nerve sites:
The cervical spine and shoulder region should be examined to rule out a diagnosis related to the elbow. Ulnar nerve entrapment has a number of differential diagnoses, such as: 
- Elbow fracture/dislocation
- Cervical Radiculopathy
- Thoracic Outlet Syndrome
- Peripheral Vascular Disease
- Ulnar collateral ligament injury
- Rheumatoid Arthritis
- Medial Epicondylalgia
- Guillain-Barre syndrome
- Alcohol (Ethanol) Related Neuropathy
- Amyotrophic lateral sclerosis
- Pancoast Tumor
- Primary Bone Tumors
- Peripheral polyneuropathy
Highlights for Physical Therapy
- A special test for diagnosing ulnar nerve entrapment has an extremely high sensitivity of 0.98 and above, making it very useful in diagnosis. 
- Conservative treatment is effective approximately 50% of the time , while surgical intervention is effective 60-95% of the time
- Conservative management has been shown to be effective when combined with splinting and manual therapy (including nerve sliding and joint mobilization); although a recent study highlighted the need for more research to understand when to proceed conservatively or opt for surgery. 
- Patients seek conservative treatment earlier rather than wait, increasing their chances of avoiding surgery by 30%
- ↑ Jan Michael C. Lleva, Ke-Vin Chang.Ulnar Neuropathy. Available from: Ahttps://www.ncbi.nlm.nih.gov/books/NBK534226/ (Accessed 30th March, 2019)
- ↑ Lauretti L, D’Alessandris QG, De Simone C, Sop FY, Remore LM, Izzo A, et al. Ulnar nerve entrapment at the elbow. A surgical series and a systematic review of the literature. Journal of Clinical Neuroscience. 2017;46:99-108.
- ↑ Jump up to:3.0 3.1 3.2 3.3 3.4 3.5 3.6 Svernlov B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur. 2009;34(2):201-207.
- ↑ Neuropathy of Ulnar Nerve (Entrapment). MD Guidelines. http://www.mdguidelines.com/neuropathy-of-ulnar-nerve-entrapment/differential-diagnosis. Accessed March 15, 2011.
- ↑ Jump up to:5.0 5.1 5.2 Ulnar Neuropathy. Emedicine from WebMD. http://emedicine.medscape.com/article/1141515-overview. Updated June 10, 2010. Accessed March 15, 2011.
- ↑ Jump up to:6.0 6.1 Palmer BA, Hughes TB. Cubital Tunnel Syndrome. J Hand Surg. 2010: 35 (1): 153-163.
- ↑ Nerve Entrapment Syndromes. Emedicine from WebMD. www.emedicine.medscape.com/article/249784-overview Updated July 31, 2009. Accessed March 15, 2011.
- ↑ Ulnar Nerve Entrapment. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00069. Updated October 2007. Accessed March 15, 2011.
- ↑ Shin R, Ring D. The Ulnar Nerve in Elbow Trauma. J. Bone Jt. Surg. (Am.). 2007: 89: 1108-1116.
- ↑ Jump up to:10.0 10.1 Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating nerve0gliding techniques in the conservative management of cubital tunnel. J Manipulative Physiol Ther. 2004;27(9):560-568
- ↑ Physical Therapy Nation. Clinician Education: How To Teach A Patient Upper Limb Nerve Gliding (Ulnar Nerve). Available from: http://www.youtube.com/watch?v=0zC3VvYg1sM [last accessed 24/10/2020]
- ↑ Spinner RJ. Outcomes for Peripheral Nerve Entrapment. Clin Neurosurg. 2006; 53: 285-294.
- ↑ Caliandro P, La Torre G, Padua R, Giannini F, Padua L.Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2016;11:CD006839.