cubital tunnel and other symptoms

makenson
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Hi,

I'm a 29 yr old Male and I'm software engineer, so I spend the whole day in front of the computer typing. I'm also a moderate cyclist, I commute to work on bike all the year and I also bike on the weekends, but I'm not a professional cyclist. I have been suffering from pain in both elbows since October 2017. I had a nerve conduction study early this year. It showed a mild nerve compression on the left elbow but didn't show anything on the right side.

Here's a more detailed story:
In Feb. 2016, I started having twitches in my body. They started in my right bicep but soon enough, the twitches were everywhere. I googled it and started to freak out. I saw a few doctors who told me it's stress related and had me pass a nerve conduction study and an emg later that year. The emg was normal, the neurologist said they're benign fasciculations and there is a 50% chance that they will never disappear, but I'll get used to them.
In May 2016, I started waking up at night with my pinky and ring fingers numb, on one or both sides. The numbness will go away within 5 seconds of shaking my hands. I went to see the doctor again, and the doc told me that I need to wear splints on my hands at night (the ones for carpal tunnel). I tried that for a couple days but since the issue kept happening even when I had the splints on, I stopped using them. However, I tried to change my sleep position and found that the issue happens less often when I sleep on my back, so I stopped sleeping on my side and started sleeping on my back. I was worried it's neck related, because I was the issue was happening on both sides and also because I felt on my back in March 2016 while playing hockey.
The finger numbness and tingling kept happening, and got worst. I started waking up sometimes with my first 3 fingers numb, and sometimes with the last two. The doctors didn't seem to know what to do about it other than proposing the splints. In October 2017, I was at work and started feeling pain in my right elbow and some light tingling in my pinky and ring fingers. Later that night, the pain was also on the left side. I saw the doctor again, gave me hand splints to wear at night and told me to take ibuprofen, and referred me to do the ncs/emg and I also did an mri to my neck to make sure it's not from the neck. The mri came fine but the ncs showed a mild compression on the left elbow but not on the right. It's odd since the pain was more severe on the right side. The neurologist also said that ncs doesn't show a carpal tunnel syndrome.
Anyhow, I started wearing the hand splints every-night, while sleeping on my back since Nov. 2017. I noticed that I wake up rarely now with numbness at night when I'm wearing the splints if I'm sleeping on my back, however as soon as I sleep on my side (even with the splints on) or if I take off the splints and sleep on my back, I wake up again with the numbness in either the 3 first fingers or the last two fingers on one or both sides.
All the symptoms I had in the last two and a half year are still present, I still get the twitching but as the doctor said I got used to it and it doesn't bother me much anymore. However the elbow pain is very frustrating. There are days where the pain is almost hidden and other days where my elbows are very painful. The right side is definitely worst.
A month and a half ago, I biked the whole day, two days after, I started feeling pain in my ring finger. Now, I'm sleeping with an elbow brace, and using the hand splints, when I wake up in the morning I close and open my right hand to see if the pain is present in my ring finger. I noticed that I only start feeling the pain in my finger after I get out of bed and flex my arm. During the day, in the afternoon, the pain goes away from the finger. I didn't have tingling in my pinky nor my ring finger except that first day where I started having the elbow pain.

1) I apologize for this long description, but I'm wondering if the cubital tunnel syndrome I'm suffering from could be caused by the same thing that causes my twitching, some sort of nerve disorders, are you aware of such a thing?

2) If my issue was just a cubital tunnel syndrome, why do I wake up at night with the other 3 fingers numb as well?

3) Having all that said, do you recommend a cubital tunnel surgery if the pain persists? If yes, at what point should I consider that it's time?

Thanks a lot!

jeremydpbland
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With nocturnal symptoms, usually, waking up with the little and ring fingers numb is a problem with the ulnar nerve at the elbow and waking with the thumb, index and middle fingers numb is the carpal tunnel at the wrist (median nerve). You can have both and which one disturbs you at any given time will depend on how strenuously you have used the arm/hand during the day and sleeping position. I am not aware of any common association between these nerve entrapments and benign fasciculation (and it does sound as though that is probably what you have from the details available). When you see multiple nerve entrapment syndromes in a young person it's always worth thinking about genetic predisposition - do you have a large family and if so have any of them had CTS or ulnar nerve problems? Do you, like many cyclists, have little arm fat so that there is not much padding to protect the nerve at the elbow? Do you have a copy of your NCS results? JB

makenson
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Hi Jeremy,
I really appreciate your quick response.
I do have a large family but none of them has a CTS or ulnar nerve problems.
True, I have little arm fat.
I don't have a copy of the NCS results, but I can ask my doctor for them.

jeremydpbland
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I'd be happy to take a look at the NCS and see how much evidence of an ulnar problem there is. JB

koen
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Hi, I'm in a similar situation as the topic starter, so I decided not to create a duplicate question but rather contribute. Important difference at my part is that I'm an MGUS'er (low risk-variant, non IgM etc) but am the same age more or less (35) and 20 year long intense power lifter, and "a bit" overweight (107 kg at 183 cm), and tend to sleep in a foetus position (arms curled up under me etc).

I also have bilateral symptoms (tingling/numbness) alternating between ulnar and median distribution, for the last 2 years or so. Only at night which woke me up around 5am, after some 'shaking' a few seconds, it all goes away. Often, I had no issues what so ever during several months, but it returned afterwards (same intensity more or less). It actually did not bother me too much. No symptoms during the day (unless I lend on my elbow a long time).

As I know there is a possible Association with amyloidosis, I went for some tests (lumbar puncture, EMG/NCV, blood) and was happy to hear my MGUS is still low risk/did not progress and they found no evidence of amyloid (although the tests are not 100% sensitive). The EMG/NCV also did not show any demyelination, but did show ulnar nerve entrapment at the elbow, but no evidence of carpal tunnel syndrome. After a recommendation to visit a physio therapist (not sure that's the right english word, I'm flemish and here it is "kinesist" :)) and wearing a towel round my left arm (which was the most symptomatic), I haven't had any symptoms (no fingers tingling/numb at night), weirdly my right arm (which I do not wear a towel for) is also symptom free.

Obviously I asked my doctors (GP, 2 oncologists, 1 neurologist) if I should be concerned regarding amyloidosis, but they all attributed it to my physique, sport occupation and sleeping postion. My neurologist and oncologist especially told me the MGUS has nothing to with it.

I know I am asking a lot in an internet forum-context, but I would like to know your take on my situation regarding potential cause. Obviously I would be happy to answer any questions. Thanks in advance.

PS: I did not get the NCV/EMG results with me. I only know my ulnar at the elbow was slowed, but my median nerve was ok apparently.

jeremydpbland
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I would tend to agree with your current doctors I think, that amyloid is not really worth worrying about for now if it's not detectable on testing and that the MGUS is probably irrelevant if there are not marked nerve conduction abnormalities. Both CTS and ulnar neuropathy at the elbow are common, so they often co-exist with other problems by chance, and your ulnar problem sounds fairly mild and under control. JB

koen
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Hi

Thanks for your quick reply. This is really a great website!

I'm indeed following the opinion of my doctors (obviously) and it's nice to hear a confirmation of that.

What interests me most, after I've read a bit about nerve entrapments, is that people with CTS or UNE (ulnar nerve entrapment at elbow) often seem to report symptoms outside of the respective affected nerve. As is the case of the topic starter and myself. +-50% (ballpark figure) of CTS patients describe extra-territorial symptoms (several papers + survey on this website), as in many UNE/CuTS (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4897207/)

I have done a bit of internet research and the main reason that keeps to come up is 'cortical reorganization and plasticity' as described in (Tecchio F., Padua L., Aprile I., Rossini P.M. Carpal tunnel syndrome modifies sensory hand cortical somatotopy) and other papers. I do not understand the details, but basically it's the brain or parts of the CNS that remaps signals or becomes extra sensitive. The fact that in many cases, as in mine, no objective evidence of extra territorial symptoms can be found other than the reported symptoms would support this. There are also papers demonstrating this process via experiments on animals and humans but I forgot which ones (would be happy to look for them if needed if this could help).

Another explanation would be that all these cases of extra territorial symptoms would be related to coincidental concurrent entrapment. I can imagine that the causative stress on body parts resulting in CTS or UNE can inflict both (body weight, activity and others are all common factors), but I would argue that more often than not objective evidence of entrapment (NCV/EMG) would be present in those cases.

Regarding the broader question posed here, based upon your experience in this field, what is your take on the frequent reports of extra territorial symptoms within CTS and UNE? Do you agree with the concept of plasticity or is the reality more complex?

makenson
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Hi Jeremy, I have the results now. I did the ncs/emg 2.5 weeks after I felt the pain in my elbows (in Nov 2017). It was more painful in the right elbow, but the dr. said that the ncs only showed a mild compression on the left side not the right side.

jeremydpbland
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expirebox insists on an overly invasive cookie policy which I am not prepared to sign up to I'm afraid. You can easily email those to me though - Jeremy [dot] Bland [at] nhs [dot] net

Regarding the previous post and the reasons for extra-territorial spread of symptoms, the cortical plasticity theory is an interesting one but it's by no means the only suggestion and in reality I suspect that there are several mechanisms, with one or more of them acting in individual patients. Some of it may be as simple as just confusion by patients in the middle of the night. It's not that rare for me to talk to patient with CTS who tells me that it is the whole hand - but then they come back a week later and say 'It's a funny thing but now that you've drawn my attention to it my little finger is normal". We do see people with multiple nerve and musculoskeletal problems so undoubtendly some of it is due to dual pathology. it is quite striking in CTS that it is the distribution of pain in particular which refuses to obey anatomical boundaries, with tingling and numbness generally keeping closer to the territory of the involved nerve. Some of the pain may be arising from visceral structures - ie the deep tissues of the carpal tunnel - and pain from internal body structures is notoriously poorly localised - the best known example being cardiac pain being felt in the left shoulder and arm as well as central chest. A part of the problem may results from alterations in blood flow as a result of interference with the autonomic nerve fibres which regulate the calibre of blood vessels..... and so one - there are doubltess other possibilites I haven't thought of. It is an endlessly fascinating subject to speculate on and we covered it a little in a recent article which is open access, but I don't think we fully understand it yet by any means. JB

makenson
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No worries, I just sent the pdf to your email address. Thanks a lot.

jeremydpbland
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Got that thanks - I'll take a look later. JB

makenson
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Hi,
I woke up this morning with tingling in my thumb, index finger and the thumb side of the palm, in my left hand. It's the first time the tingling isn't going away. I haven't had numbness or tingling in my hand at night, for a while, because I wear splints at night. But usually when I wake up with tingling in my fingers, the tingling used to go away after shaking my hand for a few seconds to a minute. What am I supposed to do now? Will it go away?

jeremydpbland
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Your NCS results show only a very mild left ulnar problem at the elbow which I would consider to be minimal at present and not an obvious candidate for early surgery. Your other nerve results are all very good, though you are young so one expects pretty good physiological performance from the nerves. Despite that you do seem to have quite a lot of symptoms which sound as though they are a result of nerve compression. Just from the history you might wonder about an inherited predisposition to nerve compression syndromes but in most such cases one would find some evidence of mild nerve dysfunction on the NCS so your very normal ones make that less likely, though you still might want to test your feet to make sure. With this morning's symptoms - if the thumb side of the palm is definitely involved then, anatomically speaking, that should suggest a problem further up the median nerve than the carpal tunnel, though your NCS did not reveal any evidence of any median nerve problem at all really. I think you are probably with the right speciality with neurology - which country are you in? JB

makenson
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Hi Jeremy,
Thanks a lot for taking the time and reviewing my ncs, I really appreciate it. I’m in the United States, in Boston. Do you know a good neurologist here? Do you recommend i find one and book an appointment?
P.S the tingling I experienced yesterday, went away, very slowly. Basically the whole day. Now I don’t feel that tingling, but I’m worried it will come back.

jeremydpbland
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I'm afraid I don't personally know anyone in Boston but there are superb medical faculties there so it should be possible to find someone.My inclination would be to get checked out by a neurologist and then as long as there is no developing weakness and no other signs of a more generalised nerve problem rely on conservative treatment at the wrists and elbow and lifestyle modification to manage this for a while rather than rushing into surgery. JB

makenson
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Ok thanks. I really appreciate your patience and help Jeremy. I will try to do that and keep in touch.

makenson
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Jeremy, I woke up this morning with tingling in the left arm, starting from the shoulder. I moved my arm quickly and it went away. That was the first time. A few month ago, I woke up with a pain in the right shoulder that felt like an electric shock. It also went away quickly and only happened once. Could those symptoms be related to the compression in the elbow, or they indicate something farther up? My neck MRI came out fine however.

jeremydpbland
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I think you need to analyse the distribution of the tingling a bit more in order to have a guess as to where it might originate. Look for diagrams of peripheral nerve and cervical root territories online and you will see what I mean - exactly where the tingling is can give you clues as to the nature of the problem. JB

makenson
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Hello again Jeremy,

First an update:
I went to see a neurologist, two weeks ago. She did a neurological clinical exam and told me that I look fine. She ordered some lab tests and found that I have an a1c level of 5.7, which is on the limit of normal/pre-diabetic (I'm not overweight, 130 lb, but my father learned a year ago that he has type 2 diabetes), she setup an endocrine consult for September to discuss the blood sugar issue, but that might not be the cause of my symptoms. The blood test also showed an ANA level of 1:40 titer, which is positive but apparently ANA titers of <1:160 may not be clinically significant. The other results, like the B12 level were all normal.
She asked me to stop biking for 6 weeks, to see if it will get better. She said, if it doesn't get better, then we'll redo the ncs/emg.

So far, it's not really better yet, even without the biking, but I'll wait 4 more weeks.

Question:
I woke up last night, in the middle of the night, I was wearing my hand splint, 5 seconds after I woke up, I started feeling an intense pain in the first three fingers of my left hand. It felt like something was being intensely pumped into my hand (blood probably?), I don't know how to describe that really, but it wasn't normal tingling. I don't know if those fingers were numb before that feeling started, because it happened so quickly after I woke up. Then, I stood up, waited for about 30-60 sec after the pain stabilized a bit, then started shaking my hand a lot, then I noticed if I leave my hand alone, I don't feel the pain, but if I close my fingers, then I hit a point where I can feel the pain again, I kept shaking my hand, and the pain went away. The whole thing took about 2-3 min. But again, that wasn't tingling. What is that? Is that because my fingers were probably numb and the blood was coming back, or is it something else? Is it suppose to feel painful like that after the fingers wake up? Is this how CTS feels sometimes? Again, I don't really know if the fingers were really numb.

Thanks again and I'll keep you updated.

jeremydpbland
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Sounds like your neurologist is doing all the right things - I said it should be OK in the Boston area didn't I. The episode you describe from last night could be an episode of median nerve compression, either at the wrist (CTS) or elsewhere - that description is similar to some that I have heard from patients with CTS though it's always difficult to convey subjective experience clearly in English. As it cleared in a few minutes I probably wouldn't worry too much about it. JB

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