Update: We have launched a new website and forums dedicated to people with cubital tunnel syndrome: www.cubital-tunnel.com
No programmers were harmed during development of this article.
(Not true… my cubital hurts like mad today!)
A programming career is supposed to offer advantages such as longevity and limited physical risk. Unlike an athlete or blue-collar worker whose livelihood depends on physical ability and can be cut short by injury or aging, most programmers should expect to work right up until retirement, as long as they can raise donut to mouth. But a nasty secret in the software industry is how repetitive stress injuries including carpal tunnel and cubital tunnel syndrome can make programming a literal pain and threaten your career.
What is Cubital Tunnel Syndrome?
Cubital tunnel syndrome (CTS) is a repetitive stress injury (RSI) that can result in moderate to severe pain and/or numbness in the elbow and ring & little fingers. Untreated, CTS can result in extreme pain, surgery or an unusable hand.
Symptoms: An Unfunny Funny Bone
Chances are you’ve experienced cubital tunnel symptoms many times throughout your life. If you have ever hit your elbow’s “funny bone,” you know what it’s like to have cubital tunnel syndrome: pins & needles & pain.
The initial symptoms of CTS are an occasional tingling sensation along the ring and little fingers and discomfort along the inside forearm near the elbow. As the syndrome progresses, the elbow may become very sore and irritated by any kind of contact. Later, the hand muscles can become numb and weak, resulting in a slow atrophy of the arm. Untreated, CTS can result in ulnar neuropathy, where the last two fingers curl into a claw grip and become unusable, similar to what you may see with cerebral palsy patients.
Quick Anatomy: Your Elbow Bone is Connected to Your…
The hand has several nerves that provide movement and sensation. The two main nerves of the hand are the ulnar and median nerves. The ulnar nerve actually starts at the side of the neck, where nerves are connected to the spine and exit through small openings between the vertebrae. The ulnar nerve travels through the shoulder, down the arm and around the elbow, terminating in the hand.
The ulnar nerve supplies feeling to the little finger and half the ring finger. It works the muscle that closes the thumb into the palm and controls several other small muscles in the hand.
The problem occurs where the ulnar nerve passes around the elbow. The nerve rests in a groove called the cubital tunnel tucked behind the medial epicondyle, the bony point on the inside edge of the elbow (see diagram below). The cubital tunnel consists of muscle, ligament and bone. You can feel it if you straighten out your arm, turn your palm up, and gently rub the groove on the inside corner of your elbow. If you tap that groove and hit the ulnar nerve, you will experience small “electric shocks” up your arm into your hand.
(Images from University of Florida Department of Neurosurgery)
Causes: Computers and Sleeping (Oh Great!)
When you bend your elbow, your ulnar nerve stretches several millimeters. While your elbow is bent, if you rotate your hand from the natural handshake position to palm down, such as when you use a computer keyboard or mouse, the ulnar nerve stretches more. Moving your fingers up and down like when typing can further stretch and relax the nerve. Sometimes the nerve will shift or even snap over the bony medial epicondyle, a very painful event.
When you have to bend your elbows, rotate your hands, and move your fingers repeatedly in the workplace, as required for most computer programmers and modern office workers, the ulnar nerve can become inflamed and irritated over time. Constant irritation may result in scarring of the ligament over the cubital tunnel, trapping the nerve and causing additional problems. The result is cubital tunnel syndrome.
Constant direct pressure on the elbow may also lead to CTS. The nerve can be irritated from leaning on your elbow while you sit at a desk, drive a car or operate machinery. The ulnar nerve can also be damaged from a direct blow to the cubital tunnel.
The most common causes of cubital tunnel syndrome are:
- Using a computer
- Sleeping on bent elbows
- Repetitive factory work
- Long-distance driving
- Playing a guitar or other musical instrument
Diagnosis: The Torture Test
I am not a doctor, so if you experience the symptoms described in this article, please see a real doctor! It’s best to consult with a hand surgeon, especially someone who has performed multiple successful cubital tunnel surgeries.
Your doctor will ask you about symptoms, which arms and fingers are affected, and whether your hand is weak. The doctor should also ask about your work and home activities, sleep positions, and any prior elbow injuries.
Your doctor will then conduct a physical exam. He/she will tap your ulnar nerve to check for tingling and shocks in your ring and little fingers, see how sensitive your fingers are to light touch and pin pricks, and measure your hand strength and dexterity. The cubital tunnel is one of several spots where the ulnar nerve can be pinched, so your doctor may need to probe and prod you a bit. This may hurt, but it’s important to pinpoint the source of your trouble.
If your doctor believes you may have CTS, he/she may order special tests to get more information about the health of your ulnar nerve. One common test is the nerve conduction velocity (NCV) test. An NCV measures the speed of impulses traveling along the nerve. Slow speed means the nerve is constricted or damaged.
An NCV test is sometimes combined with an electromyogram (EMG). An EMG tests the forearm muscles controlled by the ulnar nerve to ensure the muscles are working properly. If not, it’s often because the ulnar nerve is not working well.
I like to call this 1-2 punch of tests “The Torture Test.” If you have CTS, an NCV+EMG will be 15-minutes of shock-and-pain hell. But it’s a small price to pay to see if you have nerve damage and require surgery.
Treatment: Stop Programming!
You can reduce or eliminate early symptoms of CTS simply by stopping whatever you’re doing to cause the problem. So stop programming, sleeping on your elbow, playing the guitar, whatever. Of course, if you are a professional programmer, that’s easier said than done.
If you cannot stop the offending activities, try to reduce them. Take frequent breaks. Use technology and tools (see Prevention below) to accomplish more work with fewer keystrokes and mouse clicks. NSAIDs (non-steroidal anti-inflammatory devices) such as Advil and prescription Voltaren can ease pain and reduce inflammation of the ulnar nerve, but long-term use can result in stomach problems and ulcers.
If your symptoms are worse at night or when you first wake, use a lightweight arm splint or athletic elbow pad while you sleep to limit movement and ease irritation. The idea is to keep your elbow immobilized, slightly bent up (45 degrees) and in a handshake position while you sleep. You can also wear the elbow pad and/or wrist braces during the day.
Your doctor may prescribe you to work with a physical therapist. The therapist can apply heat or massages to ease pain, give you tips on how to rest your elbow and use the computer, and teach you exercises to stretch and strengthen your forearm muscles.
Surgery as a Last Resort
If conservative therapy doesn’t work or your symptoms become severe, your doctor may recommend surgery to relieve pressure on your ulnar nerve. There are a few different procedures depending on the patient and situation. One common procedure is ulnar transposition, which simply moves the ulnar nerve out of the cubital tunnel to the topside of the elbow. Another is ulnar decompression, which involves cutting one of the cubital tunnel ligaments to open the tunnel and reduce pressure on the nerve. Another procedure involves shaving down the bony medial epicondyle on the elbow so the ulnar nerve can shift freely in and out of the cubital tunnel.
Most CTS surgeries require a 3-4 inch incision over the cubital tunnel on the elbow, and are performed under local anesthetic as an outpatient procedure. The surgery is painful but the drugs on surgery day should help you forget.
Recovery pain and duration depends on how bad the symptoms were and which procedure was used. If you only had the medial epicondyle removed, you’ll have just a soft bandage wrapped over your elbow and therapy can progress quickly. For ulnar transposition surgery, your elbow will be splinted and immobilized for three weeks. When the splint is removed, you will perform assisted movements with a therapist for another three weeks. Active therapy starts six weeks after surgery and includes light isometric strengthening exercises. Three months after surgery you should be back in top shape, hopefully pain-free and ready to code again.
Prevention: Technology, Ergonomics and a Handshake
Because my job requires me to use a computer keyboard and mouse, I can honestly say my job is a real pain!
The first step to prevent CTS is to ensure your work environment is ergonomically correct. The key aspect for preventing CTS is to ensure your elbows are not bent too much and your hands remain in the handshake position. Next, consider wearing wrist braces while programming and an elbow splint while sleeping.
Most importantly, there are many tools and technologies that can help you to accomplish more work with fewer arm and finger movements. I will discuss each of these tools in future articles. Suggested tools include:
- Touch screen monitor
- Split keyboards
- Vertical mice such as the 3M Ergonomic Mouse
- Programmable keyboards such as X-Keys
- Keyboard shortcuts
- Program and file launcher
- Voice recognition software
- Macro software
- Automated build software
My Experience with Cubital Tunnel Syndrome
I have been writing software for 25 years. I have to admit that for the first decade of my coding career, ergonomics was a foreign concept to me and much the of the computer industry. My first exposure to it was when I joined Procter & Gamble in 1991 and was fitted with an ergonomic workstation and height-adjustable chair.
I first felt pain in 2001, twenty years after I started using computers. The pain started in my wrists and was likely a minor form of carpal tunnel syndrome, but by 2002 the pain migrated to my elbows and became more pronounced. By 2004 the pain was intense enough for me to seek medical attention from the Cincinnati Hand Surgery Specialists. An NCV test earlier this year showed some slight nerve degradation in my right arm but thankfully no permanent damage. I’ve had over three years of significant pain, but things have gotten better recently due to my treatment.
My treatment has included a night splint and change of sleeping positions, wrist braces while using the computer, Advil and Voltaren for pain, and strong reliance on all of the technology tools listed above. The most important tools for me are voice recognition, touch screen monitor and software macros.
Behind every storm cloud is a rainbow, and the upside of CTS for me is an ultra-sensitivity to bad software user interfaces. The fact is that bad UIs require more keystrokes and mouse clicks than good UIs. When every keystroke and mouse click is a literal pain, I can quickly spot UI problems. It also drives me to develop a new software system that is highly efficient, configurable, and friendly to users with disabilities. More on that to come.
Update: We have disabled additional comments on this article and moved the conversation over to our new forums at www.cubital-tunnel.com/cms/forums. Please come visit our forums and join in the conversation on cubital tunnel syndrome!
Article published on August 2, 2007
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