What should be included in the physical exam for ulnar neuropathy?

Updated: Jun 08, 2018
  • Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
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Typically, the clinical examination begins at the neck and shoulder and moves down the affected extremity to the elbow. The physical examination should include the following steps:

  • Check elbow range of motion, and examine the carrying angle; look for areas of tenderness or ulnar nerve subluxation

  • Check for the Tinel sign - This sign is typically present in individuals with cubital tunnel syndrome; however, as many as 24% of the asymptomatic population also present with the sign

  • Perform an elbow flexion test - This test, generally considered the best diagnostic test for cubital tunnel syndrome, [101, 102] involves having the patient flex the elbow past 90°, supinate the forearm, and extend the wrist; results are positive if discomfort is reproduced or paresthesia occurs within 60 seconds

  • Consider a shoulder internal rotation test - In this test, the upper extremity is kept at 90° of shoulder abduction, maximal internal rotation, and 10° of flexion, with the elbow flexed 90°, the wrist in neutral, and the fingers extended; a result is considered positive if any symptom attributed to cubital tunnel syndrome appears within 10 seconds; this test appears specific to cubital tunnel syndrome and may be more sensitive for the syndrome than the 10-second elbow flexion test is [103]

  • Palpate the cubital tunnel region to exclude mass lesions

  • Examine for intrinsic muscle weakness

  • Examine for clawing or abduction of the small finger with extension (the Wartenberg sign)

  • Assess ability to cross the index and middle fingers

  • Check for the Froment sign with key pinch

  • Check grip and pinch strength

  • Check vibratory perception and light touch with Semmes-Weinstein monofilaments - This is more important than static and moving 2-point discrimination tests, which reflect innervation density, as the initial changes in nerve compression affect threshold

  • Check 2-point discrimination

  • Evaluate sensation, especially the area on the ulnar dorsum of the hand supplied by the dorsal ulnar sensory nerve - Hypoesthesia in this area suggests a lesion proximal to the canal of Guyon

  • Exclude other causes of dysesthesias and weakness along the C8-T1 distribution (eg, cervical disk disease or arthritis, thoracic outlet syndrome, and ulnar nerve impingement at the canal of Guyon)

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