Ulnar Nerve Palsy

author : AMSSM

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Ulnar nerve injuries are common among cyclists and carpal tunnel syndrome is the only neuropathy (nerve injury) more common.

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I have been diagnosed with ulnar nerve palsy. I still haven't seen an orthopedic doctor. I am wondering if anyone has any experience with this. It started after a fall off my bike and has progressively gotten worse. I have a slight tingling in my right pinky and ring finger. Not numb but not fully there. I also have loss of grip strength especially in twisting and turning - like turning a door knob or using scissors. The first couple of days I noticed it was after long rides but then I fell on it and now it has stayed permanent.

Answer by Steve Albrechta, MD
Member AMSSM

Causes of symptoms

Based on the symptoms you describe, there are a couple injuries that may have occurred. You may have initially injured the ulnar nerve at the wrist and then the fall you experienced may have injured the nerve at the elbow. Ulnar nerve injuries are common among cyclists and carpal tunnel syndrome is the only neuropathy (nerve injury) more common.  The symptoms you describe may occur with entrapment of the ulnar nerve or compression or a direct injury. Other causes for your symptoms could be referred pain from your elbow, shoulder or even neck. Causes are also dependent on your previous history of traumas or surgeries. Location of injuries at the elbow include where the nerve passes at the cubital tunnel, near the olecranon or posterior part of the elbow, or from subluxation (inappropriate translocation) of the nerve. The cubital is the space behind the elbow where the nerve passes through, also known as the “funny bone” area. Injuries at the wrist usually occur from compression or entrapment or direct injury to the nerve within Guyon’s canal. Guyon’s canal is a space at the base of the pinkie finger in the wrist where the ulnar nerve passes through.

Ulnar nerve location

The ulnar nerve extends from your spine all the way to your hand. It travels from the spinal cord to the front of the upper arm. It then heads to the posterior side of the elbow through the cubital tunnel. It travels through the forearm muscles down the medial (inside-part) of the forearm to the wrist. It travels through an area called Guyon’s canal on the medial (pinkie) side of the wrist and then branches into the intrinsic muscles of the hand. It innervates (or gives signals and message to muscles) the medial wrist flexors allowing you to ulnar deviate (bend towards pinkie finger side) your wrist. It provides innervation to some of the muscles deep inside your hand that allow you squeeze your fingers together and grip objects. It also provides sensation to the 5^th finger (pinkie) and half of the 4^th finger (ring finger). Depending on the location of the injury will determine the symptoms you may experience.

Common injury locations

The two areas the ulnar nerve tends to be injured are at the elbow in the cubital tunnel or at the wrist near Guyon’s canal. Many bicyclists experience symptoms after injuring the nerve at the wrist from putting weight on the wrist on their handlebars and also from repeated shocks or bouncing at the wrist from the handlebars. Based on the symptoms you describe initially, you may have had positional transient paresis (temporary sensation loss) from repeated trauma to the wrist. The fall you experience may have caused an injury to the nerve at the elbow giving the more permanent symptoms you describe. 

The location of the injury and severity may require evaluation by a medical professional. They will ask specifics about the symptoms, examine your arm and hand and then may utilize imaging. The images would check for any fractures at the elbow or wrist that may be affecting the ulnar nerve. A nerve conduction study may then be utilized to specifically locate the injury. An ultrasound or MRI may be chosen to assess injuries to the nerve. 

Ulnar nerve treatment

Treatment for ulnar nerve injuries at the elbow or wrist is first with conservative measures. This includes avoiding motions with the arm that bring on the symptoms. It also includes using splints or devices that limit motion. These help to prevent repeated injury to the nerve. You may be fitted for a splint from a sports medicine therapist. While you wait to be evaluated, you can try wrapping a towel around your elbow to help prevent full elbow flexion. When symptoms begin to improve, you will need to begin strengthening the muscles that may become weak from decreased use. Strengthening the muscles of the wrist and the intrinsic hand muscles will retrain the nerve to allow proper healing and prevent the muscles from becoming too weak. Medications can help improve your symptoms. You should discuss this with your healthcare professional and follow their recommendations. If symptoms are severe or do not improve initially with conservative measures, surgery may be needed.

Injury prevention

Preventing injury is important to continue enjoying your sport while being injury-free. Ways to prevent ulnar nerve injury includes properly fitting your handlebars to the correct height and grip based on your riding posture. You can also buy gloves with medial wrist padding to decrease the shock your wrist experiences. You need to also strengthen your core muscles to decrease the amount of weight you place on your wrists while riding. If you do begin to experience similar symptoms, you should be evaluated by a medical professional. Early treatment will allow for a speedier recovery and quicker return to activity. 

Steve Albrechta, MD
The Ohio State University
Family Medicine Residency Program, PGY-2
Rardin Family Practice Center

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date: August 5, 2013