Let me preface this by saying I'm not a doctor . . . and I don't play one on TV!

This entry is all about the impinged ulnar nerve in Jim's right arm. It didn't exactly "tickle his funny bone," but instead has caused significant muscle deterioration and weakness between the thumb and forefinger in his dominant hand, plus numbness and tingling in his outer fingers when cycling.

After a nerve conduction test and physical examination by an orthopedist who specializes in hand surgery, his condition was diagnosed as Cubital Tunnel Syndrome AKA Ulnar Nerve Entrapment.

Graphic from the link in the quote at the top of the page

His hand got so bad that non-surgical treatments weren't effective, so Jim decided to have surgery to release the nerve in both his elbow and his wrist several weeks ago.

The good news is that his recovery is going well. Only time and consistent home physical therapy will tell if the muscles are able to rebuild their mass and strength between his thumb and forefinger. The numbness/tingling in his fourth and little finger is gone.

This is not a well-known medical condition, so I'll try to describe it here from our lay persons' perspectives and the help of the internet.

CARPAL VS. CUBITAL

Most folks have heard of carpal tunnel syndrome, which is often caused by too many repetitive motions like using keyboards on computers and other electronic devices. There are other causes, too, as described on the American Academy of Orthopaedic Surgeons' (AAOS) website.

Pressure on the median nerve on the inside of the lower arm causes swelling in the carpal tunnel, which results in pain, numbness, tingling, weakness, and/or muscle wasting in the affected hand.

Here's a diagram from the AAOS link above of the median nerve and carpal tunnel:

Treatment of carpal tunnel syndrome starts with conservative non-surgical methods like braces, changes in activity, physical therapy, NSAIDs, and steroid injections.

If those aren't successful, surgery may be indicated to prevent irreversible damage to the hand. The goal is to release the pressure on the median nerve so it can function normally again after some time and physical therapy.

Most of the above is true for cubital tunnel syndrome, too, except it involves a different nerve, the ulnar nerve:

As you can see from the diagram above that I found during a Google search, the ulnar nerve passes through the inside of the elbow at the cubital tunnel, down the lower arm and through the another tunnel in the wrist called Guyon's Canal, then leads to the four fingers and the muscles between the forefinger and thumb.

Compression or stretching of this "funny bone nerve" can cause numbness or tingling in the ring and small fingers, weakness/muscle wasting in the hand, and/or pain in the forearm.

Jim had those first two symptoms, most noticeably in his right (dominant) hand.

LOSING HIS GRIP?

Jim wasn't fully aware of the muscle wasting until our primary care physician in Virginia pointed it out to him in a routine physical exam about four years ago.

Jim mostly thought losing his strength and grip was part of the aging process. At the time our doc mentioned the problem, we were focused on selling our house so we could become full-time RVers. With that accomplished, we began traveling all over North America for the next three years.

Worthington Glacier north of Valdez, Alaska is in the background; that's our Cameo 5th-wheel. (6-17-15)

Medical continuity was a challenge during that period of time, and stopping long enough somewhere for surgery wasn't part of the our plan unless absolutely necessary.

Jim's hand finally got so bad, however, that he decided to seek advice from an orthopedist near our new home in October of this year. He consulted with Dr. Virginia Jones, a hand specialist with the large Ortho Atlanta orthopedic practice that has offices all over the metro Atlanta area.

(We've now seen four different orthopedists in this practice, for various body parts and a nerve conduction test, and highly recommend them.)

Dr. Jones' initial exam included medical history and testing Jim's strength and grip with both of his hands. His dominant right hand was much weaker than the left hand and the muscle wasting (atrophy) in his right hand was also obvious just by looking at the two hands.

Jim failed a simple grip test on the affected hand with a piece of paper between his thumb and forefinger -- he couldn't firmly grasp it like he could with his non-dominant hand.

My brother later quipped that he bet Jim would have held on tight if a $20 bill had been used!

Yep, Jim might have latched onto one of these
better than a blank piece of paper!

That day Jim got cortisone injections in both hands and a splint for his left "trigger finger" thumb.

Cortisone has worked fairly well for both of his hands previously but it is only a temporary solution for pain and doesn't address the deteriorating muscles in his right hand at all. The splint has helped make the left trigger thumb more comfortable as Jim waits to decide whether to have surgery for that problem someday.

NERVE CONDUCTION TEST

Dr. Jones described Jim's problem on his right hand as "peripheral neuropathy" but she didn't diagnose Cubital Tunnel Syndrome for certain until he had a nerve conduction test a few days later. She referred him to another orthopedic specialist in the Ortho Atlanta practice, Dr. McHenry, for that test to give her more specifics about the problem with Jim's right hand.

Jim was apprehensive about having the nerve conduction test done but knew it was necessary to pinpoint the problem and address it properly. He had terrible pain in his neck and back a couple years ago after a nerve conduction test in Jacksonville and swore he'd never undergo such testing again.

Fortunately, this time all went well -- he had no pain afterwards and Dr. Jones got the information she needed to properly diagnose his problem and how to fix it.

We truly are a bundle of nerves!
This diagram is from the LiveScience website.

Dr. McHenry explained after the nerve conduction tests that Jim had ulnar nerve impingements in both his right elbow and wrist, not just the cubital tunnel in the elbow.

When we went back to see Dr. Jones' PA a few days later, we learned that Jim's best option would be surgery. Anything less than decompressing the nerve in both locations would mean he'd continue to lose muscle mass and strength in that hand. Further delay was not a good option.

Jim pretty much decided then and there to schedule out-patient surgery with Dr. Jones at the nearby hospital complex where I had my knee surgery.

I certainly encouraged him to get it fixed once and for all. By that time I was mostly back in commission around the house after having my first total knee replacement so I could do more of the chores, drive short distances, assist Jim with eating and dressing, etc. while he was recovering.

This was his dominant hand and arm, after all, so he'd be more limited in what he could do for himself than if it was his other hand/arm.

IT'S A SMALL WORLD!

Jim's out-patient surgery was scheduled for Friday, November 3.

In the intervening time, he got medical clearance for surgery from our new primary care physician and had his pre-op appointment with Dr. Jones. I went with him to the appointment with Dr. Jones so I could learn more about the surgery that would be done the next day.

Jim wore one of his Leadville Trail 100-mile shirts to that appointment -- and Dr. Jones noticed it immediately when she entered the room.

Would you believe, her husband did the LT100 bike race in 2014!!  Jim did it in 2013.

Jim powers up to 12,600 feet elevation at Columbine
Mine during the LT100 bike race on August 12, 2013.

We talked with Dr. Jones about the hundred-mile foot and bike races in Leadville for a little while.

Small world. Who-da thunk?

Jim was relieved after talking with Dr. Jones more about the surgery even though she didn't think she'd be able to use the least invasive of three possible techniques to relieve the pressure on the ulnar nerve in the elbow.

She wouldn't know exactly which technique was required until she saw during surgery what was going on inside his elbow. The day before surgery she thought he might be one of the 10% of patients with similar symptoms and nerve-conduction test results that require the more invasive surgery where the nerve has to be moved over about an inch.

Normally the ulnar nerve lies in a groove on the inner side of the elbow. Here's another graphic from the AAOS website:

From what Dr. Jones said, even the technique that is most invasive and slowest to heal sounds like it has an easier recovery period than what Jim had been reading about and watching on the internet.

That says something about how much credence we should put in what we see on You Tube! Sometimes it's very helpful but other times it just makes us worry too much.

At that point we were hoping that Jim will have more use of his dominant hand sooner than he thought he would. Even so, we finished up some things around the house and yard the day before surgery that would be impossible or difficult for Jim to do for several days or weeks after surgery, like heavy lifting, vehicle maintenance, and yard work.

DAY OF SURGERY

Jim had to be at the out-patient surgery center at Piedmont Fayette Hospital (next photo) at 8 AM. We took Casey and Holly, our younger Labrador retrievers, to Puppy Tubs for day care first, then went to the hospital.

 

After check-in Jim had to wait about 50 minutes to go back for pre-op. The chairs were comfortable in the waiting room and I had HGTV to watch, so the time went by faster for me than for Jim.

No matter how "easy" any surgery may sound, there is always some understandable apprehension. Jim just wanted to get it over with.

They called me back to see Jim after he was in his gown and an IV was inserted in his hand but before he got a nerve block and good drugs to relax him. One of the anesthesia team members came in to ask questions and get signatures re: insurance, then Dr. Jones came in to talk with us.

Jim looks pretty relaxed and ready to go into surgery. He never lost his sense of humor.

At this in-patient hospital and out-patient surgery center all the medical folks ask the patients for their  name and DOB, what it is that they're having done, and where on their body. They did the same thing in September when I had my knee surgery.

It's obviously to ensure they have the right patient, the right procedure, and the right body part!

When Dr. Jones came in she asked Jim what he was having done and he joked, "I thought you knew!" She laughed.

We like Dr. Jones. She's personable and just cool, and we feel more of a connection after finding out her husband is an ultra-distance cyclist (he also runs). She also knows her stuff. In eight years of doing hand surgery, she's performed about 200 cubital tunnel syndrome procedures per year, about 300 carpal tunnel procedures each year, plus other types of hand surgery.  

The nurse asked me to go back out to the waiting room when Jim got his nerve block; he went into surgery soon after that. After about 40 minutes I was called back to speak with the doctor.

She said everything went well during surgery and she didn't have to do the most invasive procedure that would involve moving the nerve near the elbow an inch over. She said the nerve was very "congested" at both the elbow and wrist but she was able to release it in both places. She described it as the nerve saying, "Ahhhh, I have room now!"

Incision for cubital tunnel release in Jim's elbow

Incision for the other tunnel release in Jim's wrist

Dr. Jones also talked with me about wound care and what activities Jim could do until he went back for his first post-op appointment. Then she returned to the operating room.

Jim was her sixth of eight surgeries that day.

After a few more minutes I was allowed to be with Jim in recovery. The nurse took out his IV and he was able to get dressed. He was released after a relatively short time in the recovery room. (Although he was asleep during surgery, it didn't take very long so the anesthesia wore off pretty fast.) We got a prescription for Tramadol for pain, and written post-op instructions.

We left the hospital at 11AM, just three hours after our arrival, and went to Subway to get enough of his favorite turkey sandwiches for lunch the next four days for Jim. We went to Puppy Tubs for "the girls" (Holly and Casey) and got home before noon.

Not a bad morning, considering!

RECOVERY 

Jim's recovery from this surgery was more inconvenient than painful.

For the next few days he iced his arm every waking hour as instructed and mostly sat on the couch with his feet propped up, reading, watching TV, or dozing:

 
Holly-pup was especially curious about Jim's sling and the pillows
he used to elevate his arm as instructed to reduce swelling.

Jim's arm was numb from the nerve block until bedtime the first night. He needed Tramadol for only a day or two, and just Celebrex and/or acetaminophen to relieve the pain from the surgery (and various arthritic joints) after that.

He wore the sling on his arm in bed for a few nights so he didn't roll over and tear the incisions accidentally in his sleep.

He wore the sling less and less during the day as he was able to do more things and didn't have to keep his arm stationary. Until his first post-op appointment, Jim was instructed to move his arm and fingers as much as was comfortable to increase the blood flow and range of motion but not lift anything that weighed more than eight pounds. That's the equivalent of a gallon of milk.

With increased movement of his arm, he had trouble keeping the ACE bandage on. After several days of struggling with it, he kept it off some during the day and used it mostly at night and in the shower to cover the gauze bandages on the incisions.

Although we used a large plastic bag to cover the Ace wrap and gauze bandages when he took showers, he sometimes got the incisions wet. We had to change the elbow and wrist bandages at least once a day to keep the incisions clean. I don't know why something like AquaCel bandages was not used; the AquaCel that covered my long knee incision in September allowed me to shower with ease and stayed intact for five days until I was supposed to take it off.

When Jim went back in for his first post-op visit, his incisions looked good and nothing was mentioned about getting them wet. No harm, no foul, just a PIA for us with the bandages.  

OH, TO BE AMBIDEXTROUS!

Some activities were difficult or impossible for several days after surgery because Jim's dominant hand was sore and even weaker than before surgery. He also had to be careful not to tear the stitches out.

If you're like most people, you have a dominant hand (and leg). If you're one of those people, just imagine what life would be like if you had no or very limited use of that hand for a while.

How would you cut a piece of meat on your plate into bite-sized pieces? How would you tie your shoes? How would you unscrew a tight lid off a jar -- or your bottle of pain medicine? Those pill containers can be hard enough to get into with two good hands.

Occupational therapy addresses these and other issues if a patient will be handicapped in this manner for a longer period of time or has no one at home to help him/her.

Fortunately, Jim didn't need that because his limitations would be temporary and I was there to assist him. He was also pro-active and initiated his own version of occupational therapy.

Right-handed people have a dominant left brain; ambidextrous brains are more symmetrical.

For a couple weeks before surgery Jim was wise to practice doing more things with only his left hand -- using a fork or spoon to eat, brushing his teeth, combing his hair, typing on the computer and phone keyboards, getting dressed and undressed, even going to the bathroom.

Yes, he was able to laugh about most of this, although I'm sure he got frustrated sometimes at things that were awkward or even impossible with just one hand. He knew it was just a temporary condition.

I did what I could to make things easier for him after surgery, like cutting his food into bite-sized pieces. There was no way initially that he could cut a chicken breast, for example. I unscrewed jar lids and the tops of pill containers until he could grasp them with both hands again. He also needed some assistance with tying his shoes for a few days, putting bandages on, and covering his arm with a plastic bag for the shower.

Some things he simply could not do for one or two weeks -- drive, lift more than eight pounds, mow and do other yard work, ride his bike outside (he used the indoor trainer as soon as it was comfortable), work on the vehicles, climb the ladder into the attic, and some other activities.

All these restrictions were lifted after his post-op appointment with Dr. Jones eleven days after surgery. She was pleased with his recovery and rate of healing. His stitches were removed and Steri-Strips put over the incisions; they stayed on a few days, then fell off as intended.

PHYSICAL THERAPY

A few days after his post-op visit with the surgeon, Jim had an appointment with a physical therapist with Ortho Atlanta who also specializes in hands. The goal is to build back the muscles that have atrophied between the thumb and forefinger in his dominant hand.

This putty is for PT, not for play.

That's the only formal session the therapist says he'll need as long as he continues doing the strengthening exercises regularly -- and maybe forever -- at home.

Instead of weights, balls, or stretchy bands, common physical therapy tools, he only needs one glob of "hand therapy putty" material for his exercises. It reminds me of the "Silly Putty" I used to play with as a kid.

Online you can purchase several different colors from Amazon, Walmart, and other sources. Like therapy bands, each color represents a different level of resistance. Jim's therapist gave him yellow putty.

I found his sheet of exercises online on the FlintRehab site. It's the same sheet Jim got from his therapist:

I assumed he'd have to use some sort of ball for his exercises. However, squeezing a ball doesn't work to strengthen these particular muscles.

Apparently only hand therapy putty will do.

PROGNOSIS AFTER CUBITAL TUNNEL SURGERY

According to Dr. Jones and what we've read on the internet from reputable orthopedic sources, the results of each of the types of cubital tunnel surgery are generally good.

As with any surgery, recovery from cubital tunnel surgery varies quite a bit from one individual to another in regards to which symptoms go away (numbness, tingling, muscle atrophy), to what extent (from not at all, to totally), and how long it takes (from pretty quickly to a long time -- or never).

The more fit you are, the better you'll recover from any surgery.
We've had this book since 2008 and re-read it every couple of years.
Our knee orthopedist recommends it to his patients, too.

Cubital tunnel symptoms may not go away totally after surgery, especially if the symptoms were severe. If the nerve was very badly compressed or there was serious muscle wasting like Jim has, the nerve may not be able to return to normal and some symptoms may remain. Because nerves recover slowly, it may be a while before we know how well Jim's ulnar nerve responds to surgery.

Since Jim has the beginning of the same symptoms in his other hand, he is scheduled to have a nerve conduction test on his left arm and hand in early December. He wants to get ahead of the damage in this arm/hand so the muscles don't atrophy as badly as the one he had repaired.

Depending on the results of the test, he may have surgery on that arm/hand in January or February. He won't know until he consults with Dr. Jones again in mid-December.

It's been just three weeks since Jim's surgery. He has regained most of the functional use of his right (dominant) hand and has resumed all of his normal activities. The numbness and tingling in his fourth finger and little finger disappeared soon after surgery; that was a problem primarily when he was cycling.

Casey sure was happy when Jim could get back out on his bike!

It will take a while to see improvement in the atrophied muscles between his thumb and forefinger. A lot will depend on how regularly he does his hand putty therapy.

Next entry:  We got snow!! Photos from a rare, and fleeting, winter wonderland in Peachtree City

Happy trails,

Sue
"Runtrails & Company" - Sue Norwood, Jim O'Neil, Cody, Casey, and Holly-pup

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