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Playing the guitar isn’t easy. It requires incredible precision, hand strength, dexterity, and endurance to perform well. Some of the most devastating injuries I see in guitarists from day to day are injuries to the nerves that innervate the arm. When nerves are compressed or irritated, guitarists can experience pain, numbness/tingling, muscle weakness, decreased dexterity, and an inability to play for prolonged periods. This series of articles is to outline some of the more common nerve compression syndromes I see in my practice and teach you what causes these injuries, how to recognize them, what can be done to treat them, and how to prevent them from occurring. Today we will be starting with a lesser known injury affecting the ulnar nerve, called Cubital Tunnel Syndrome. Ulnar nerve entrapment is the second most common nerve entrapment of the upper extremity (1) (the first is carpal tunnel syndrome), and can be very problematic for guitarists. Research has shown that musicians are among the population groups that are at risk for developing Cubital Tunnel Syndrome, along with truck drivers, baseball pitchers, and constant cell phone users (2).

Causes and anatomy

Have you ever hit your “funny bone” on a piece of furniture and felt that electric like zing into your baby finger? As it turns out, your funny bone isn’t a bone at all; it’s your ulnar nerve. The ulnar nerve begins at the neck, just as all the nerves in your arms do. From there, it travels down the inside of the arm alongside the triceps as it approaches the elbow. At the elbow, it passes between the big bump on the back of the elbow (called the olecranon process) and the medial epicondyle, which is the pointy bit of bone on the inside of the elbow. If you put your finger in the space and rub back and forth, sometimes you can feel the ulnar nerve. It feels like a piece of spaghetti. You may even feel that zinging sensation a little bit as you roll over it.

As the ulnar nerve enters the forearm, it has to pass beneath a muscle called flexor carpi ulnaris. This muscle has two distinct parts, and a fibrous bridge that connects the two of them. The first head attaches at the olecranon process of the ulnar bone, and the other attaches as the medial epicondyle of the humerus. The space between these two muscles and under the fibrous bridge is called the Cubital Tunnel. The ulnar nerve passes through the Cubital Tunnel, where it continues throughout the inside of the forearm. It puts off small branches to innervate some muscles that control wrist motion, and those that bend some of the fingers. It then travels through the medial portion of the wrist, and into the hand. Once in the hand, it sends branches toward the thumb and into some of the fingers. These branches of the ulnar nerve are responsible for a multitude of functions. Some are used for relaying sensation from the little finger and half of the ring finger to the brain. Others help with controlling the motion of the 4th and 5th fingers. There are even branches that innervate the muscles that allow you to spread your fingers apart and bring them together, as well as pulling your thumb inward, just to name a few. These all sound like important things for a guitarist to have good control of, don’t they?

When a nerve is compressed, its ability to send signals back and forth with the brain is impaired. This can manifest as weakness of the muscles innervated by that nerve, numbness/tingling or lack of sensation in the skin it innervates, and electric-like shooting pain throughout the course of the nerve.

Signs and Symptoms

Cubital Tunnel Syndrome often begins with achy pain and soreness near the inside of the elbow as the irritated and overworked muscles become inflamed. As the tissue swells and the muscle tightens, it puts pressure on the nerve, which can cause a burning sensation as the nerve becomes more and more irritated. As inflammation increases, and pressure builds up against the nerve, the nerve may become compressed, and neurological symptoms result. Patients may experience numbness and tingling into the 4th and 5th fingers at this point. Nerve compression impairs the nerve’s ability to control the muscles it innervates, so weakness in the muscles outlined in the previous section may be noted. Fine motor skills in the hand will also be significantly diminished. If the neuropathy is not dealt with quickly, the muscles can begin to atrophy away with disuse, leaving the affected hand looking less muscular than the other side.

Upon physical examination by a trained professional, some classic signs of ulnar neuropathy may be noted. When asked to spread their fingers apart and then pull them together again, the patient will likely be unable to pull their pinky finger in. This is called the Wartenberg Sign, and reflects weakness in the interossei muscles that control this motion. Another test that may be done is looking for Froment’s Sign, in which the patient is unable to hold a piece of paper between their index finger and thumb without bending the last joint of the thumb, reflecting weakness in the muscle that pulls the thumb toward the index finger. The practitioner may also note that the patient is unable to feel light touch or distinguish between sharp and dull in their 4th and 5th fingers on the affected side. Tapping with a finger or reflex hammer over the Cubital Tunnel may cause the zinging sensation or an increase in numbness/tingling. The practitioner should perform a thorough exam of the entire upper limb and neck, and take all the information they have gathered into account before making a diagnosis. It’s important to rule out the neck and shoulder region as a potential contributing factor as well (see my upcoming article on Thoracic Outlet Syndrome).

Treatment

Once a diagnosis of Cubital Tunnel Syndrome has been made, a treatment program needs to be put together to repair the damage that has been done, and fix the underlying issues that caused the nerve entrapment in the first place. Recovery times depend on the severity and how long the issue has been happening, but it can often take up to 3 months for the injury to resolve. Here are some of the various strategies a health care team may choose from to treat this condition.

Activity Modification

It’s important that whatever aggravating activities you are performing are discontinued (1). I hate to say it, but this often means taking a break from playing guitar. Repetitive use of the 4th and 5th finger can tighten up the muscles in your forearm that are compressing the nerve, which makes matters worse. It’s also important to avoid repetitively bending your elbow, so a good doctor/therapist will go over your daily tasks with you to determine where your activities need to be modified to prevent the condition from getting worse.

Splinting or bracing

Using a splint or brace at night can help prevent the elbow from flexing fully, which will stretch the ulnar nerve too much and cause increased symptoms. The elbow is typically braced at 45 degrees in a neutral position (1). It's important that the elbow is not braced all the time, as prolonged inactivity can lead to atrophy of the muscles which will then need to be rehabilitated later. Only wear a brace with the instruction of a trained medical professional, and follow their instructions carefully!

Soft Tissue Therapies

Focused massage therapy can help relax the affected muscles that are causing nerve compression, relieving symptoms. Some professionals use stainless steel instruments to get a deeper and more focused massage. Always see a licensed and registered professional for any of your muscle work. There is a big difference between a masseuse and a registered massage therapist when it comes to their training and expertise.

Anti inflammatory medication

Some practitioners will prescribe anti inflammatory medication to decrease the swelling in the area. Never self prescribe medication. Always consult with your doctor or pharmacist before taking anything!

Ice

Applying ice can help decrease inflammation and take pressure off the nerve. It is important that you ice the tissue for a maximum of 10 minutes at a time, and then take it off for at least 10 minutes. This is because if ice is left on for too long the blood vessels will open up in the area to prevent frost bite, which effectively increases the inflammation in the area, which is counterproductive. Try icing for 10 on and 10 off for up to an hour.

Electroacupuncture

Sterile needles can be inserted close to the nerve to help release muscle tension, relieve pain, and stimulate the nerve. When electrical current is applied, it can cause the nerve to be activated beyond the point of entrapment. This is particularly useful for slowing or preventing atrophy in the muscles of the hand that aren’t able to function on their own. There hasn’t been any research done on electroacupuncture with Cubital Tunnel Syndrome specifically, but many experts find good results with this technique, and it has been shown to be helpful in Carpal Tunnel Syndrome for all the same reasons (3).

Stretching/strengthening

Stretches are often prescribed for patients to perform at home to help relax muscle tissue and encourage it to release. Grip strength and forearm exercises are used to strengthen tissue in the area and encourage proper healing. Exercises are prescribed based on your individual case and what your body requires specifically.

Nerve flossing/mobilization

The goal of nerve flossing techniques is to encourage the nerve to gently slide back and forth beneath the entrapment site as it normally would, much like dental floss glides back and forth between your teeth. This technique involves putting your body into a position that will pull on the nerve in one direction, while relieving tension on the other side of the entrapment. The position is then reversed, so the side that was once tense becomes slack, and the previously slack side it tensioned, allowing the nerve to glide back and forth. Some techniques involve applying tension at both ends, and many therapists have slightly different techniques, but generally the principle is the same.

Surgery

If all else fails, surgery is an option. There are a variety of surgical techniques available to reduce pressure on the nerve, although experts cannot agree on which approach is the most effective (1)(4), although some approaches have been shown to carry lower risk of infection (5).

Prevention

Even if you have never experienced Cubital Tunnel Syndrome, you can probably agree that it doesn’t sound like something you would ever want to have. Take the following steps to help prevent it from happening:

1. Warm up and cool down properly each and every time you play. See my previous article (6 Tips to Help Guitarists Stay Injury-Free) for some tips on how to do that.

2. Give yourself frequent breaks. Breaks allow your forearms time to rest and recover from the load playing puts on them, and helps prevent repetitive strain injuries.

3. Get your forearms massaged. Pay a visit to your favorite local registered massage therapist and have them treat your forearms to relieve the tension before it becomes a problem. At the very least, look up some self massage techniques so you can loosen up your own forearms.

4. Eat right. As the saying goes, you are what you eat. If you aren’t giving your body the proper nutrients to repair damage and increase your strength and stamina, you’re setting yourself up for disaster. Visit a clinical nutritionist in your area to make sure your diet is giving your body what it needs.

5. Hit the gym. Conditioning your muscles will go a long way to improving muscle tissue strength and prevent injury. Make sure you’re working on the smaller muscle groups in your body, not just the big ones that everybody knows about. Consult with a rehab focused chiropractor or physical therapist if you’re not sure what you’re doing.

6. Gradually increase your playing time. I have seen a lot of amateur guitarists who have decided to take their playing more seriously, and drastically increased their practice time overnight. Since your body isn’t used to playing for long periods, you need to ease it into the new demands. Practicing too long too early can cause injuries.

7. Gradually build up strength in your 4th and 5th finger. Who doesn’t want their weaker fingers to be stronger? Running drills focusing on your pinky and ring finger can be very helpful to improve your speed and effectiveness as a guitarist, but don’t overdo it! Take a few minutes each day to strengthen these fingers, and gradually increase the time you spend focusing on them. If you’re overzealous about it, you could end up causing a nerve entrapment instead of preventing it.

I hope you have found this article enjoyable and informative. If you have any questions, feel free to comment below or contact me directly. Let me know what other topics you would like to learn more about, and keep an eye out for more articles in this series to come including Carpal Tunnel Syndrome, Thoracic Outlet Syndrome, and Pronator Teres Syndrome.

About the Author

Dr. Tim Lahn is a Chiropractor and avid musician in Barrie, Ontario. He is passionate about treating musicians with injuries, and educating them about their bodies and the unique challenges presented by their instruments of choice. His ultimate goal is to get his patients back to the studio and the stage, doing what they love to do. To book an appointment call Complete Care Chiropractic (www.completecarechiro.ca) in Barrie at (705) 722-3131. To reach Dr. Tim Lahn directly contact drtimlahn@gmail.com

For more tips like this, follow Dr. Tim on Instagram at @drtimlahn and on Facebook at www.facebook.com/timlahnhealth

References:

1. Palmer BA, Hughes TB. Cubital tunnel syndrome. J Hand Surg Am. 2010 Jan;35(1):153-63, commentary can be found in J Hand Surg Am 2010 Sep;35(9):1556

2. Bradshaw D, Shefner J. Ulnar neuropathy at the elbow. Neurol Clin 1999 Aug;17(3):447

3. Vincent C.H. Chung, PhD. Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial. CMAJ, June 2016 DOI: 10.1503/cmaj.151003

4. Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg. 2007 Nov;15(11):672-81

5. Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2012 Jul 11;(7):CD006839