cubital tunnel syndrome

Whistle
1

I few weeks ago I started a thread on
problems I was having with my hands.
Got lots of good advice. Since then
I’ve seen a doctor; today I saw
a physical therapist. I thought I’d report
to you’all–in case you ever run into
this sort of thing.

The symptoms are tingling and numbness
in the pinky and ring finger. The cause
is compression of the ulnar nerve, typically
(but not necessarily always) at the
elbow where it runs through the
cubital tunnel, under the funny bone.
The nerve gets compressed and starved of
blood when the elbow is bent.

Sleeping with the elbow bent is
a principal cause. The therapist is
wanting to make me a custom brace
that will stop that. A second cause
is repetitive flexing of the arm,
as in pushups, boxing, etc.
A third cause is prolonged bentness
(as in sleeping with the elbow bent or,
sadly, playing whistles).

Night splints are indicated, typcially,
Avoid resting elbow on tables/armchairs.
Avoid exercises that straighten
elbows, like pushups bench presses.
Try not to bump your elbows. Wear
protective pads. Avoid prolonged
flexion (bentness)–lots of breaks.

The nerve by your elbow is sometimes
compressed by a muscle that bends
your wrist. Stretching the muscle
5 times a day for ten seconds is
recommended. Basically you hold your
arm out straight, grab the hand with
the other hand, and bend it up and
back for ten seconds.

I’m switching to low whistles, cause
the angle of the arms is wider. Boxing
may have to go (repetitive flexing)
and weight lifting doesn’t seem a good
idea. Looking back I’ve been using my
arms a whole lot in the ways that
lead to this thing, as well as
sleeping with them flexed at night.
Lots of word processing everyday, too.

The physician was very reassuring about
recovery. The OT therapist much less so.
The therapist was more helpful
in a practical way.
Would welcome more tips, if any, as ever.

Thanks to all

2

Hi Jim

This is all we had on Cubital Tunnel Syndrome , and it sounds very similar to what your PT has already told you. Remember this material was written for players in the “small strings” section of a symphony orchestra, so some of the info isn’t entirely relevent.

"This form of entrapment neuropathy is common to violinists, but may occur in viola players, particularly involving the instrument arm. It involves the entrapment of the ulnar nerve as it passes along the inner aspect of the elbow. The nerve is particularly vulnerable in this position as it passes under fibrous bands of muscles. The instrument arm is often maintained in elbow flexion and shoulder external rotation, which places tension on the nerve as it passes around the elbow. The symptoms include pain at the elbow, and sensory sensations (pins and needles, tingling, burning, numbness) in the area of the little finger of the hand. If the condition is allowed to progress you may notice weakness and incoordination of the fingers of the hand. This will particularly debilitate the fingering hand as the ulnar nerve directs the muscles that help move the fingers sideways.

Modification of activity
This is the first thing that you should do when you first feel symptoms. If you get to the symptoms early enough modification of activity may involve only increasing the frequency and duration of rest breaks and a reduction in the amount of time that you are playing. You may reduce the duration of
practice, but increase the frequency. So instead of a two hour session what about doing 30 minutes, go for a walk etc. then resume for another 30 minutes.

When you first become aware of symptoms sit down and think “is there anything else that I am doing that may be contributing to the symptoms?”. It may be necessary to stop these extra-musical pursuits for awhile until the
symptoms settle. Sometimes we are too keen to blame the instrument playing when it is in fact due to other activities.

Consider your playing posture. Do you think that your posture may be part to blame. It may be necessary to reconsider your playing technique. Get advice from an experienced colleague or music teacher. We are never too
old to learn new techniques, and it may be that your technique has subtly changed, increasing the stress through the arms. Try playing in standing (if you play the violin or viola) instead of sitting and see what effect this has.

Complete absence from playing should be avoided. Playing even a little bit, will maintain some form of physical and mind- muscle conditioning. But play only up until the point of discomfort, don’t play until it hurts.

Physical Therapy
It may be necessary to commence a course of physical therapy treatment to help ease symptoms and facilitate the healing process. Treatment may consist of stretching the tight muscles, strengthening weak muscles, local
massage and various electrical modalities that aim to facilitate the healing process. You may even be prescribed a splint to wear at night, or during the day, to allow the area of the body to rest adequately, whilst still allowing you to function with your activities.

Before you play, try doing some stretches and warm up exercises. Try a cold pack placed over the area during your breaks and when you finish playing.

Remember though that no matter what treatment you decide to undertake you will still need to modify your activity to allow the treatment to work."

Hope this is of some help Jim!

Rob



[ This Message was edited by: Mastersound on 2002-04-24 20:32 ]

3

Tell me about your boxing training Jim, what exactly does it consist of? Which of the following are you working - focus mitts, shadow boxing, heavy bag, double end bag, uppercut bag, speed bag?

Are you doing 10 3 minute rounds switching from one to another, or are you primarily working one piece of equipment at a time for several rounds?

What about sparring: How often? Do you miss landing your punches frequently?

Does your training include push-ups and or passing the medicine ball?

Finally, and perhaps most important, how are you wrapping your hands? How many windings are you getting around the wrist? When you wind around the wrist, are you actually winding around the joint, or below the joint, closer on the forearm, a common mistake. Are you using standard or “Mexican” hand wraps? Which brand, Ringside?

I have a little experience in this area, perhaps I can help you rule out some potential causes of the problem.

Loren

4

P.S. Don’t forget to mention what sort of defensive drills you’re doing - you can leave out footwork and things like practicing the bob, slip and weave - we’d be primarily concerned with drills that have you actually blocking, deflecting or absorbing punches.

Loren

5

Dear Rob and Loren, Many thanks.
Rob, this stuff is all well taken.
I’ve read your message several
times.
I’ve reached the conclusion that
excellent posture and position are
a very good idea for their own sake,
and perhaps minimize the possibility
of getting into trouble.

Loren, I’m doing usually 6 3 minute
rounds, followed by many situps.
Davy varies what I do from lesson
to lesson. Focus mits, speed bag,
a big cylinder with a water base,
an ugly rubber man, occasionally the
heavy bag. There’s a speedbag sort
of device standing vertically
on a long spring, about head height.
I often come in alone and hit the
speed bag, the vertical springy thing,
and the rubber man. I occasionally
miss hooks to the springy thing. Jabs, right
crosses, left hooks, right hooks,
uppercuts, etc. Combinations.
Punching things is good for the soul.

I’m using ringside Mexican style wraps,
following the instructions. I’ve
got an Ace wrist wrap around my right
wrist (which I may eliminate, cause
I seem to be hurting myself less
than before). I wrap following instructions.
Some go around the joint, others
go a very short way up the forearm.

I’m supposed to start sparring soon.

Thanks, fellas, much appreciated.

6

I don’t know too much about the boxing stuff, but am curious about the situps - done with hands locked behind the neck?
As to the physical therapy treatment, please find out what kind of splint the therapist is talking about making. If it’s going to be one of those low temperature thermoplastic ones that goes from the upper arm down to the hand, please know that these are generally not well tolerated by the person wearing them. IMHO, far better to even use what you were (IIRC, a towel wrapped around your arm.) I use some wrap around soft splints that, when properly applied, permit a small amount of movement at the elbow without excessive bending. There is also a rather nice product sold by North Coast Medical (although, unfortunately, not on their website) which consists of a neoprene sleeve with adjustable upper arm portion, a gel cushion insert at the elbow (for the padding portion), and a low temperature thermoplastic insert that goes on the inside of the elbow and is molded to allow full extension and limit flexion to whatever amount is desired (typically around 30 degrees), serving as a stop at that point. This would be great for daytime use, and could be worn at night, as well. Believe me, your arm will like something that allows some movement better than a splint that keeps your arm fixed in one position. (And don’t blame the therapist; the one piece rigid splint is recommended in the premiere two volume hand therapy book put out by some top notch experts in hand surgery and therapy.)
One other thing I’ve found to be helpful is the use of tart cherry juice concentrate. Check out http://www.LeelanauFruit.com/ and make your own determination.
If you do much driving, I also suggest using some sort of vibration absorbing gloves. These are available for folks who work with industrial machinery from glove suppliers.
There are probably more ideas, but these will do for a start.

7

Thanks, Jim. I sent you a private
message a few days ago, and here’s
the info I wanted.

No, situps aren’t with hands locked
behind head.

Since posting this morning I talked
to the physician’s nurse (he’s out
of town). She says he won’t prescribe
a custom splint, thinks it’s too
expensive or whatever.

They gave me a couple of ‘heelbos’
which look like stockings with
a gel insert–you can wear
the insert on either side of
the elbow. At night it’s supposed
to go on the inside. I find these
too little to stop myself from
flexing in my sleep. Any way I’m
consoled by your negative views
of the custom made jobby, which
was exactly what you describe.

On the other hand I went out and
bought a device manufactured
by Corflex–an injection molded
plastic back, some soft stuff
inside, velcro straps. You wear
it on the back of your arm.
Quite uncomfortable, but it
keeps you at 30 degrees. Expensive,
though.

I’m not driving hardly at all. Will
definitely check out the juice.

This really is a strange experience.
The medical personel tell me different
things; very hard to figure out
what’s really going on, etc.

About 4 years ago I went to Europe
for 6 months to teach. As soon as
I arrived in England I had awful pains in my
left foot. At no point in this next
6 months was I able to find out
what was the matter. Went
to hospitals, etc. What is there
to do in Europe but walk? So I did
anyway–quite a time! Frightful
pain and lots of fun, both at
once.

In Innsbruck,
where I taught, a shoemaker,
the ominously named Herr Hobble,
made me 300 dollar inserts of leather with a
rubber ball that went under the
metatarsal. Herr Hobble and I
had no language in common, and getting
these fitted and adjusted was quite
an experience. We had long
arguments because I was saying I
wanted the thing higher and he
was also saying the thing should go
higher and thought I was saying it
should go lower. Herr Hobble and
I became friends and I sent
him postcards when I returned
to the states. The inserts never
worked, never at all.

I also spent
150 dollars on sandals with crystals,
magnets, and various bumps designed to
stimulate your endocrines, which
I gave away finally to the chairman of the
philosophy department, Father Rungaldier.
He was delighted with them.
I’m afraid he has left the Jesuits
because of the stimulation to
his endocrines.

When I got back to the states I
somehow found
an ad for felt inserts by a company
called ‘Hapad,’ which described a
condition called ‘Morton’s neuroma,’
which I instantly recognized as
what I have. The felt pads cost
15 dollars and fixed the problem
right away.

Thanks and best to all, Jim

8

On 2002-04-25 23:44, jim stone wrote:

I also spent
150 dollars on sandals with crystals,
magnets, and various bumps designed to
stimulate your endocrines, which
I gave away finally to the chairman of the
philosophy department, Father Rungaldier.
He was delighted with them.
I’m afraid he has left the Jesuits
because of the stimulation to
his endocrines.

Heehee. So that’s what it was… I am glad to see that your not losing you sense of humor. :slight_smile:

9

Jim,

Funny how the doctors and PT’s never really seem to know what’s going on, eh? Well, actually, it’s not funny at all, but you know what I mean.

Re: The Boxing: As a professional Martial Arts and Boxing instructor, I taught hundreds of people to punch, and hit things in general. Never in 20+ years have I ever seen a single case where Boxing, or it’s related training, caused CTS. I have, very rarely, had students who, already having the condtion, got worse while training.

When this happens, it’s not the repetitive arm motion in and of itself that causes the problems, rather it’s repeated small traumas (“micro injuries” if you will), that cause swelling in the tissues around the Ulnar Nerve. These Micro Injuries are caused by poor technique, lack of wrist/elbow/shoulder strength, and lack of adequate wrist support.

My suggestions to you, based on my direct experiences, is this:

First, lay off the heavy bags, totally. Hitting the heavy bag is the single most damaging thing you can do to your shoulder, elbow and wrist joints, in the gym.

Musclar strength builds far quicker tha tendon and ligament strength, so people are able hit a heavy bag far harder than they have any business doing, long before they have the ligament strength to support the force generated in the joints when your fist collides with the bag - Triple so if you have less than perfect technique and lay into the bag without proper structural alignment of the bones and joints.

IMO, with exception of people in their 20’s and younger, no one should be hitting a heavy bag without a year or so of training under their…gloves - the joints and tendons just can’t handle the stress of weak tendons and ligaments plus undeveloped technique.

Hitting the focus mitts, speed bag, and your sprinloaded friend the “Cobra” bag. should be fine. The exception here would be if trainer is really pushing back hard at your punches with the focus mitts, in which case you might ask him to tone it down a little.

Also, be very careful about punching hard when you may miss the target completely (Spring loaded “Cobra” bag, focus mitts, sparring) because a tremdous about of (bad) force is generated in the elbow when you miss a punch and get some hyperextension going on.

Finally, dump the flimsy mexican wraps and switch to the standard Ringside cotton wraps. The Mexican wraps look cool and are quite comfortable, but provide MUCH less support at the wrist than the standard type wraps. Hey, don’t get me wrong, I love Mexican wraps, use 'em all the time, but then I’ve been hitting things for going on 28 years now - so I can get away it :slight_smile:
Well, there you have my advice FWIW Jim. As Hans and Franz were wont to say “Hear me now and believe me later!”

Now for some on-topic whistle subject matter!

As I recall you’re quite happy with you latest Abell A whistle (did you get the Bb tube as well, I don’t recall?), I’m curious what you feel is different about this whistle when compared to the one we both tried (at different times) a couple of years ago?

You see, I’m tempted to order another A/Bb from Chris, plus a high F, in order to complete my Madagascar Rosewood set. However, I’m still not sure the A/Bb are worth the dough based on my previous experience.

I assume you’re having no clogging problems with this set? How is the bell note? This note was weak enough on the sets A/Bb sets I’ve tried in the past to be a bit of a deal breaker…

Good luck with the physical thing man, I can totally relate :frowning:

Loren

10

Thanks, Loren. I’m relieved that
your experience is that boxing
doesn’t cause, or typically aggravate,
CTS. The physician said there’s
no problem, the therapist said,
to stop. It’s immensely
good exercise and also it’s
quite helpful psychologically.
Really would prefer to keep
at it, especially as I’m slowly
getting better at it.

I’m not doing much on heavy bags,
and I’ll keep your advice in
mind. I was hurting my hands
and wrists occasionally on
the focus mits and elsewhere,
but things have improved as
I’ve become more experienced;
also better at wrapping my
hands. Yes, I’ll think seriously
of moving to regular cotton
wraps.

I like the blackwood Bb/A set
much better
than the delrin set. There’s a
little clogging initially,
which stops quickly–afterwards
no clogging problem. But
the whistles are quiet and
I don’t think the bell note
can be described as strong.
They sort of grew on me
in the way Abells do.
I think they get better
as played, and the sound
of blackwood verges on
angelic.

Thanks again!

11

Jim,

Thanks for the thoughts on your Abell A/Bb set.

Sorry about all the grammar and typo errors in my last post, yikes! I get sloppy late in the day and I’m just too lazy to re-read those long posts these days. Too bad I can’t spell check with my system, oh well.

Anyway, yeah man, keep up with the boxing if at all possible - It’s great for your heart, lungs, muscles, bones, and head (well at least as long as you’re not getting hit in the head too much :slight_smile:)

Again, good luck with the physical problems, I know it’s a bitch.

Loren

12

Jim,

I Forgot to ask: Did you get your Blackwood Abell set new or used? There really does seem to be a significant “play-in” factor with the Abells, so I’m wondering if you got a set off the shelf, or already broken in a bit.

Loren

13

I thought your spelling was impeccable.
That says something about my spelling,
maybe!

I got the set new.

14

Sorry…I just noticed this thread and had a few comments (about the thread, not a blackwood Abell set).

After having the outer three fingers on my left hand go numb from too many repetitively bad activities (computer programming and whistle/piano/organ/violin/guitar/Uilleann pipes/GHB playing) I had to have surgery to have the nerve moved. After making a foot-long incision over the left elbow they freed the ulnar nerve and moved it around the elbow so it doesn’t get stretched as much. After two weeks in a cast the doctor told me the recovery period is about a month per inch of nerve moved, meaning almost a year of pain around the elbow.

Since the surgery I have gone back to programming (gotta eat!) and whistle-only playing (gotta whistle!). Thanks to my wonderful HMO no physical therapy of any sort was allowed!

It’s nice to see some good advice from others in a similar situation and not what the paid baboons who show up occasionally in white coats in my hospital spew out.

15

Geeze John,

That sucks! And no PT?!?! That’s downright criminal! Our freaking health care system (or lack thereof) blows. :frowning:

Having had a couple of knee operations myself, I can relate to your situation a little. That’s a pretty radical surgery you had, how are you doing now?

Loren

16

I hope it helped, John. I’m getting
what’s called ‘conservative treatment.’
The surgery you had is the alternative.

About 6 years ago I started getting
bad pains in my knees. I went to
3 different orthopaedists, who
recommended surgery. ‘We won’t be
able to give you a new knee, but
a better knee’ they said.

It never quite added up. I went to
a fourth orthopaedist who had me
walk across the floor barefoot.
‘Your flat feet are catching up
with you,’ he said. He explained
that I was pronating lots,which
was stressing my knees. Meanwhile
I was one of these silly academics
who doesn’t get enough exercise,
so the muscles in my legs were
too weak to control the knee joints.

‘Why don’t you get on an exercise
bike for a few weeks, and see how
you feel,’ he said. I did. The
pain went away.

There was nothing to do surgery
on.

I have friends in the Mafia, and
considered offing the first
three orthopaedists. (The Mafia
will give you three contracts
for the price of two.) Maybe I did;
maybe I didn’t.

17

My doctor didn’t give me any alternatives…either have it done now by me or there’s nothing that can ever be done for it. Can you spell “scalpel happy”?

The biggest problem now is that my funny bone is on the inside side of my elbow and that everybody & everything is always hitting it. Especially when I work on the computer and prop my elbows on the chair it puts pressure on the nerve and everything on down goes numb. At the movies, when I’m relaxing in a chair, whatever…the arm goes numb with any pressure.

The only consolation is that I can play my music again! Before, I had lost almost all sensation in the two smaller fingers and a lot in the middle finger.