Injury Analysis: Ulnar Nerve Entrapment

Like most climbers, when I first started I dove right in the deep end. I would climb every day for as long as I could. Of course, this quickly lead to injury. I developed fairly severe pain on the inside of my elbow, which I assumed was tendinitis. I even went to the doctor (more than one) and they confirmed my suspicion. They told me to rest, do exercises, etc. but it never went away. It wasn’t until maybe 5 years later that I went to a good physical therapist who actually found the real issue. This experience, and a few others, has drastically decreased my faith in M.D.’s for treating injuries, but that’s a rant I won’t get in to here.

For those five years when I went to the doctor, I would point to my elbow, just about the bone and say “it hurts right here,” and the doctor would say, “that’s weird, it’s probably medial epicondylitis (golfer’s elbow), but that’s usually painful below the bone. Go to physical therapy for  golfer’s elbow.” Finally I went to a doctor that just said, “I have no idea. Let’s make you pay for an MRI, get nothing out of it and have the P.T. figure it out.” So instead of having the P.T. just follow orders, this time he diagnosed me. As soon as I pointed to my elbow above the joint he said it was ulnar nerve entrapment, and he fixed it in one session.

There are three major nerves that run from your neck all the way to your fingers: ulnar, median, and radial. The ulnar nerve runs along the inside of your arm and ends in your pinky and ring fingers.

https://i1.wp.com/orthoinfo.aaos.org/figures/A00069F01.jpg

If you’ve ever hit your “funny bone,” or you’re pinky and ring finger fell asleep while leaning on your elbow, that’s the ulnar nerve.

So what is entrapment? Well, it’s exactly what it sounds like. The nerve gets trapped at a location then when you move your arm the very taught nerve gets yanked and causes pain. What’s tricky about a nerve issue, is it generally causes referred pain, meaning the site of the issue can cause pain in another area. So with the ulnar nerve, a very common symptom is tingling in the fingers, even though the compression is occurring in say the elbow. However, tingling is not THE symptom; I never had tingling which is why I went undiagnosed for so long. Also since the nerve is so long, there’s many possible sites for it to be compressed. In my case, I was having pain in my elbow, but the compression was happening in my shoulder.

https://classconnection.s3.amazonaws.com/694/flashcards/597694/jpg/median_nerve1310963435466.jpg

The culprit was pectoralis minor. You can see in the picture above that all three major nerves combine together in the neck and the pec minor (cut away in picture) runs over the bundle. The pec was super tight and squeezing on the nerve. If you have climber’s hunch you probably have tight pecs and you probably are susceptible to entrapment at this location. Can you guess what the best fix is? The fix that probably would fix about 80% of all neck, back, and arm issues?? Posture! Sorry folks, your parents and cranky old middle school teachers were right. Sitting up straight is good for you. What really drove this point home for me was something I heard Dr. Jared Vagy, aka The Climbing Doctor said. A lot of climbers (myself included) think “oh I got some shoulder pain from climbing,” but what percentage of the week are you actually climbing? Maybe 10%? And what percentage are you hunching over a desk or a work bench or sleeping on your stomach with your neck wrenched to one side? Yeah, that’s what’s probably causing your pain and what needs to be fixed. “But Nerd, sitting up straight isn’t comfortable!” I know I agree and I struggle with posture all the time, which is why I’ll go through some more specific things you can do to help with ulnar nerve entrapment.

Ok let’s think about what’s happening. The pec is tight and grabbing the nerve, causing it to get stuck and pull at the elbow. So how do we fix this? Well first let’s loosen up the pec. Stretch it out you say? Not yet. A massage therapist once told me that you can think of knots kind of like actual knots in a rope. If you have a loose knot in a rope and you stretch the rope, all you’ll end up doing is tightening the knot. So before we stretch the pec, let’s loosen up the knots. Here’s a video of how to work the pecs with the trusty lacrosse ball. Also, if you’re not familiar with Kelly Starrett, check out his channel. He has mobility exercises for just about anything.

Ok, now that the tight spots are worked out we can stretch the pec. For me, doing a normal pec stretch will actually pull more on my ulnar nerve so I prefer to do a light, but longer (1 min) stretch on the foam roller:

http://legitmassage.files.wordpress.com/2012/07/foam-roller-1-legitmassage-com.jpg

More of a relax the muscles instead of stretching them. The final step is to address the nerve itself. What we want to do is get the nerve running properly through it’s tunnels and channels. To do so, you have to floss! Yet more things your parents told you to do as a kid ;). “Flossing” the nerve after the major tension is released will further loosen up any other sticking points. So like I said before the nerve anchors in the neck and fingers. The goal is to first pull the nerve towards  the fingers then back towards the neck so you’re literally flossing it through the rest of your arm. Here’s a video demonstration.

I’ll usually do about 20 reps and my elbow pain will be gone immediately. One note while doing these: nerves don’t really stretch. So if you’re feeling a lot of tension in the nerve while doing this, you’re not really getting the full benefit.

This protocol has worked wonders for me and hopefully if you have elbow pain that is persistent and treating for golfer’s elbow isn’t working, looking at the ulnar nerve will help!

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8 thoughts on “Injury Analysis: Ulnar Nerve Entrapment

  1. Wondering if you have a more precise description of your symptoms. I got something that I’m fairly sure was golfer’s elbow (I could pretty clearly feel the ache in the tendon itself) that went away after doing some of the recommended exercises. But ever since, I’ve also had a dull pain in my elbow — particularly in the mornings, like with tendinitis — that is just stubbornly unresponsive to any treatment I can find. It’s about in the same spot as the tendinosis but seems slightly less localized to particular tendon. What’s especially odd about it is that I mostly can’t trigger it by simply working my wrist around, like I could with the golfer’s elbow. Instead, the pain seems to be related to the degree of extension of my elbow: the more my arm is bent, the more it hurts. In particular, bending my arm and pushing down with the bottom of my palm (e.g., pushing the bottom edge of my hand against my ear) hurts quite sharply. While I’ve no doubt the injury is somehow related to climbing, actual climbing doesn’t seem to especially aggravate it — but some days it flares up for no discernible reason.

    Any of this sound familiar? It’s a long shot, but the mechanics of the nerve as you’ve described them might explain why pressure on a hand would cause pain in a bent (but not straightened) elbow .

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    1. What you’re describing still sounds like golfer’s elbow to me. I just got over a bit myself and I had the exact same symptoms: pain when pressing against my head and no pain while actually climbing. What really cleared that up for me was Active Release to loosen up the muscle pulling on the tendon.

      As for the ulnar nerve pain, it was very localized to right above the elbow, pretty much on the nerve itself. If you put your finger right on the medial epicondyle and go slightly above that you should feel a thick band. That’s the ulnar nerve. Also the pain was more of a burning rather than an ache.

      Hope that helps.

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  2. Hey mark!
    How quick did you notice improvements? It’s funny we always thought it was tricep tendonitis but I could always feel the ulnar nerve along the medial epicondyle . I’m considering art therapy a couple times but I’d like to see if i can just roll out the chest to see what is causing the entrapment.

    Anywho, cheers.

    Zach

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    1. Hi Zach,

      Improvements were immediate. After my first session with the PT that taught me those exercises all the pain dissipated. It did slowly creep back, but that was the first break I’d ever had. As I kept doing the exercises and going to PT, it would take longer and longer for the pain to come back, until eventually it never did! I would say maybe try doing the exercises once a day for a week and if it’s not significantly better, then ulnar nerve might not be the culprit.

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      1. Thanks mark.

        I’ve been doing the exercises for a while but not daily and or consistently. I will do so for a week or two and see if there is any noticeable improvements. I’m almost certain it has something to with my ulnar never because I can feel it move over my medial epicondyle every time there is flexion or extension in my arm and it gets aggravated.

        Thanks for your help though , your initial post on here helps enormously.

        Zach

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  3. Whoa I’m glad to read this…I slammed my elbow against a wall last November and I’ve still been struggling with nerve pain on the inside of my elbow just below the bone. Same deal with me, I went to doctors who didn’t have a clue. I stopped climbing altogether for 4 months and instead focused on rest and accupuncture/cupping and massage 3 times a week. Still though, the pain exists. It’s better than it’s been but it’s still there. Lately I’ve tried going to Bikram yoga basically 4-5 times a week and that’s been helping but I really, really fear I need surgery. I’m getting an MRI tomorrow to see what’s what but everything I’ve read about ulnar nerve entrapment describes what I have. Now I have pain located in my elbow, it’s annoying and limiting but I don’t have a claw hand or anything like that. I’m wondering if I stick to the bikram, nerve flossing and swimming daily if I’ll be able to rehab on my own physically without having to go under the knife? I did climb with the injury but I stopped out of concern for the fact that I was going to mess it up more. I see you climbed for 5 years with this injury. Have you been climbing this entire time after discovering your diagnosis as well? I’d really like to get back to climbing again, any feedback you have is great appreciated and thank you for writing this post!!!

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    1. Hi Paul!

      I was able to fully recover from the nerve issue and have been able to climb continually since then. It will still bug me from time to time (it’s actually a little angry as I’m writing this), but if I do the flossing and some chest opening stretches it will subside. My entrapment was chronic though not acute, like hitting my elbow against the wall. My pain was never below the bone either, always above, i.e. closer to the armpit. I’m not a doctor, or any type of health profession, so I can’t really say with any certainty if just nerve flossing will be as effective for you as it was for me. If I was in your situation, I’d probably get the MRI just to be sure there was no damage due to the elbow slam. If they don’t see anything, I’d guess working with a good PT will get you fixed up. Look for a sports PT. From my experience regular PT’s mostly see elderly patients and go too easy to be effective for athletes. If they do see something on the MRI, go to multiple MD’s for multiple opinions!! I popped a finger pulley a few years ago and the first doctor immediately said I needed surgery. He said I should have surgery on another finger that was just kind of sore just to be safe too. Ridiculous! Next doctor I went to said that I was fine and to just do some PT exercises and it’d heal. So yeah just proceed with caution. Sorry I couldn’t be more helpful :(.

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  4. Hi,

    Thanks for your post.
    I have both golfer’s elbow (GE) and ulnar nerve entrapment (NE). I have tingling and lesser range of flexion which indicate ulnar nerve problems and muscular pain while flexing and doing pulling exercises like one-hand chin ups, which indicate GE.
    According to one study, the GE might cause NE. I quote:
    “The existence of other upper limb work‐related musculoskeletal disorders was also found to be a risk factor. Such disorders include medial epicondylitis (golfers elbow) and other upper limb entrapment syndromes such as cervicobrachial neuralgia, carpal tunnel syndrome and radial tunnel syndrome”

    I’m going to change my home set-up since I work with a computer and try the flossing, as I don’t really understand all the trigger point stuff.

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