The Ulnar Nerve
Wednesday 1 May 2019
My Amazing Body is a podcast where we explore interesting, unknown and misunderstood parts of your body with help from medical experts and stories from real Queenslanders.
This episode is all about the ulnar nerve, which you might be most familiar with as the part of your body that causes so much pain when you hit your ‘funny bone’. Occupational therapist Belinda Bond teaches us about how the nervous system, and in particular, the ulnar nerve, works, and how you can keep your nerves happy and healthy. Special guest Kat tells us what it was like to learn she had a tumour impacting her ulnar nerve, and takes us on her journey from diagnosis to treatment and recovery.
Meet our guests
Audio is great, but some things are best seen as well as heard. These materials provide more information about topics we touch on in the show.
The nerves of the arm and hands
Host: When was the last time you hit your funny bone? It's not very funny, and it's actually not your 'bone' that causes that sharp, tingling pain in your arm. When you hit your funny bone, you're actually hitting the largest exposed nerve in your body, the ulnar nerve.
Hi, I'm Elise and welcome to the latest edition of the My Amazing Body podcast, where we explore interesting, unknown and misunderstood parts of your body. Today, we're learning about the nervous system, and in particular, the ulnar nerve.
Kat: My name is Kat, I'm 27-years-old, and I live in Brisbane.
Host: A few years ago, Kat noticed her forearm hurt after playing volleyball. Volleyball can be pretty tough on the arms, so at first, she didn't think much of it.
Kat: What happened to me was back in 2016 I was playing volleyball at the time and I discovered a pain in my arm. And it was in the forearm so I thought that with volleyball you're constantly hitting the back of your fingers and your fingers are pushing back, so I thought I'd just done some muscle damage. So naturally I just left it for a year, roughly.
Host: But unlike a strained muscle, Kat's pain didn't go away with time. In fact, it got alarmingly worse.
Kat: I was at work and I rested my arm on my desk while I was typing away and it was excruciatingly painful. Straight after that I thought, “Oh, there's something wrong”, so I decided to finally go to the doctor.
Host: After ultrasounds, x-rays and finally a CT scan, Kat got some unexpected news. A tumour was growing in her forearm. The pain she was starting to feel when she rested her arm on her desk, was the pressure of the tumour impacting the nerves in her arm.
Kat: The tumour that I was diagnosed with was called a neurofibroma and they're naturally benign tumours, most of the time. Obviously, there's a chance that they can turn malignant, pretty much just like any other tumour. But the reason that they're an issue is they either grow inside a nerve or wrapped around a nerve, and the type that I had it was wrapped around a nerve.
So, when the surgeon said that the best option was to go in for surgery and to remove it, he explained to me at the start that there could be some damage to the ulnar nerve because it was so close to the ulnar nerve. And he sort of described it as if, you know, it could be, I guess, a lot of damage in the sense that I would lose a lot of feeling in pretty much my entire right arm. Or it could be that there's no damage or it could be just sort of a 5% loss. So, he did definitely describe that to me at the start and that was a risk that I had to decide whether I wanted to go ahead with the surgery, and I think at the end of the day I'd prefer to have a bit of loss of function than a tumour where I didn't know whether it was cancer or not.
Host: Nerves and nerve injuries, like those caused by Kat's tumour and the surgery she needed to remove it, require expert care. When it comes to nerves, and the ulnar nerve in particular, Belinda Bond is that expert.
Belinda: So, my name's Belinda Bond, I'm an occupational therapist and team leader occupational therapist at Ipswich Hospital. So, I predominantly work with people with hand injuries in a rehab type role so getting people back to work, back to function, back to what they need to do after they've had an injury that affects their hand or arm.
So, nerves are the super highway of the body, they transmit information so they help us to feel and see and interpret and interact with our environment.
Host: Belinda explains that all of our everyday experiences rely on the operation of our nerves.
Belinda: Okay, so nerves are really important, but they're not something we talk about or know much about unless we injure our nervous system. Super important, though, they allow us to function. If our nerves don't work we can't walk or talk or do what we need to do on a day-to-day basis and we can't get information from our environment, we can't see, we can't hear. All of those systems are reliant on nerves.
The nervous system has two main divisions; it has a voluntary component and an involuntary component. And obviously the involuntary component are things like regulations of blood pressure and the rate of breathing and we're not aware of our body doing that it just does that all by itself which is fantastic. But the somatic system which I guess what we're talking about today, and the ulnar nerve is part of the somatic system, consists of nerves that connect the brain and the spinal cord with muscles, but also with sensory receptors. So, they give us the information about the environment, but also send our muscles the messages so that we can walk and talk and function in the way that we need to.
Host: Because nerves are so sensitive, if you injure them - like when you smack your funny bone and hit your ulnar nerve - the pain can be extreme. But you don't need to hit your funny bone to feel the ulnar nerve at work. Even if you just gently tap your arm in the right spot, you might be able to feel the tingling sensation from your ulnar nerve.
Belinda: So, all of our nerves for the upper body and the lower body arise initially from the spinal cord, so they come out through the shoulder, through a group of nerves called the brachial plexus. I always like to put my hand on the front of my shoulder when I'm demonstrating that to people, and the nerves are there for like the fingers of your hand and they travel in different directions. So those three main nerves the radial nerve, the ulnar nerve and the median nerve all travel and wrap around your arm. Specifically though, the ulnar nerve travels around the back of the arm so if you come around to the back of your arm, come down towards the elbow, and you'll probably feel at the elbow you might be able to feel the ulnar nerve if you trigger that funny bone type response and then it travels further down your arm, down into your little finger and half of the ring finger.
Host: While Kat's tumour was impacting her ulnar nerve and other nerves in her arm, Belinda says there are much more everyday ways to injure your ulnar nerve.
Belinda: So, the classic one is striking your funny bone, but typically that resolves quite quickly so as soon as you remove your arm from the hard surface, and usually give it a rub to distract yourself, that numbness and tingling goes away. But problems arise when that nerve compression lasts for longer so I see, rowers for example – I'm demonstrating a rowing action but you can't see that – but you can imagine when you're rowing you're constantly flexing your arm and then extending, and it's that protracted or longer-term elbow flex position that makes the ulnar nerve quite vulnerable to longer term injury and compression.
Host: For clarity - when Belinda says flexing your arm, she's talking about bending it.
Belinda: Rowing is common. Often people sleep – we see particularly people in winter that sleep in that really curled up position, really heavy sleepers maybe people that take sleeping medication, to help themselves sleep – that sleep in that flex position it leaves that ulnar nerve really over stretched and vulnerable for a prolonged period of time, so the nerve's compressed for, you know, hours at a time, and then that sensation of numbness and tingling and pain doesn't go away so it remains and that becomes a real problem.
So, typing's a really common one that can stir up the ulnar nerve and it often doesn't just stir up the ulnar nerve it makes the median nerve quite unhappy as well where the median nerve crosses at the wrist if people are typing in a position of wrist extension where the wrist is coming back, the median nerve gets squashed and that's that classic carpal tunnel symptoms that people experience, it often needs surgery to correct. But typing, similarly, if your workstation isn't set up appropriately and your sitting really close to your computer and you're sitting with your elbows quite tightly flexed, then the ulnar nerve can be compressed in that position so typing and office work, particularly if your workstation isn't set up ideally, is problematic.
Host: Belinda stresses that if someone has symptoms of nerve problems anywhere in the body, they need to see a specialist as soon as possible, so that physical therapies can be given and surgery doesn't have to become the only treatment option.
Belinda: So, if someone has damaged their nerve either through repetitive use as we’ve described, and from sport or from their work, the symptoms that they'll classically experience are the numbness, tingling, pins and needles, and that's particularly problematic, as I said, if those symptoms hang around, so a brief compression to a nerve should resolve within 10 seconds I would say, maximum. If it goes longer than that there's a potential for damage, and longer-term damage, so they're the classic symptoms: numbness, pins and needles, tingling pain that doesn't resolve quickly.
Ideally, you would get it early if you have ulnar nerve compression and certainly if anyone has any ulnar nerve symptoms or other nerve symptoms, we'd certainly say seek intervention sooner rather than later because the longer that compression hangs around, the more problematic it becomes and the less likely it will respond to conservative intervention. So, if you're getting any of that pins and needles, numbness or pain that doesn't resolve quite quickly, seeking intervention potentially getting a referral to an OT or a Physiotherapist that works in this area.
Host: Are you ready for this episode’s mystery body part? See if you can guess what the body part is from the clues given. We’ll reveal the answer at the end of the episode.
I’m come in all sorts of shapes and sizes, but I’m usually dark in colour. I can be flat or raised. I happen when melanocytes, or pigment cells, grow in a cluster. Most people will find between 10 and 40 of me on their body. Do you know what I am?
Host: Belinda often works with patients who have had surgery on their arms or their hands, and says that nerves are notoriously finicky if disturbed.
Belinda: Yes, in my experience once you operate on nerves and you get in and you move them around they take a really long time to settle, they really don't like being moved or touched or handled, and you can develop this condition called neurapraxia which is essentially the bruising of a nerve and, you know, that takes a long time to recover from.
Host: For Kat, surgery to remove the tumour was her only treatment option, but it came with risk; her surgeon couldn't tell her what kind of nerve damage she'd have when she woke up.
Kat: So, straight away after the surgery I couldn't really move my hand, especially the pinky finger and the ring finger of that hand. Those are the two that are mostly affected by the ulnar nerve shutting down.
Host: While the surgeon had been able to successfully remove the tumour, he'd had to touch the ulnar nerve in the process.
Kat: When I woke up from the surgery, I didn't feel anything in my arm, so I thought, I think I expected there to be pain, I think when you go in for surgery you just assume straight away that you'll be in a lot of pain. But for me I didn't feel anything. I could sort of move my arm around and there was no pain, no discomfort or anything like that.
So, the lack of pain was mostly because they had fiddled around with the nerve, so particularly the ulnar nerve because it is such a big function in that part of the body they said to me that when you push aside a nerve like that, they just stop, so the way he said it was that they go to sleep. And he said that it takes a really long time for them to wake up. My surgeon said that it can take up to 18 months for some people for a nerve like that to be woken up.
Host: After a short recovery period, Kat saw an Occupational Therapist like Belinda, who helped her regain function in her arm and her hand. Kat quickly gained a new appreciation of how complex her body was, and how much she had taken it for granted before her surgery.
Kat: So, straight away with the exercises that my therapist got me to do, I had to place my hand on a table and really had to try and think about moving my fingers. And that was a really strange feeling because you're telling your brain to do something and telling your body to do something but, when it physically can't do it, it’s a bit of a shock. But after about a month when that sort of kicked in and my hand woke up a little bit and I was able to at least just lift my fingers off the table, that was really good progress.
Following that, she gave me some, like stress balls, different strength stress balls, and I had different exercises like having to pinch the stress ball with every finger on that hand, because right at the start for about a month it was sort of my whole hand was affected, so I had to regain the strength in all of my fingers right at the start. And then towards – it was probably about three months down the track – it was focussing on those bottom two fingers and that’s where she brought in some other tools like putty, there's different strength putties that you can use, so I was using that for quite a while.
Having that surgery gave me a massive appreciation of what the body can do and I think right at the start when I had the exercise of laying my hand on the table and having to try and lift my fingers, it is something so simple and just not being able to do that really highlights, I guess, how complex the body is but also how complex the brain is.
Host: When there is damage to the nerves of the arm, including the ulnar and median nerves, a syndrome called 'claw deformity' can occur. This happens when some or all the fingers are pulled backwards, so they start to curl in towards the palm, kind of like a bear claw. While we don't often think about how our fingers sit when we're not using them, Belinda says that clawing can be very debilitating.
Belinda: Basically, the little and the ring finger pull back, so they sit and it makes that hand look like a claw. So, it's very difficult to close your hand and the little fingers really involved with power gripping so ultimately people will become quite weak, they won't be able to, you know, lift or carry or squeeze repetitively, and that can affect driving and lots of other areas of function. So that claw deformity is quite debilitating, and therapists will often make anti-claw splints to try and prevent that posture, because long term it's really quite dysfunctional.
Host: Kat wore one of these splints in the months after her surgery, to stop clawing from becoming a permanent disability.
Kat: When I regained the strength in the other three fingers of that hand so the thumb and the top two, it was just the bottom two clawing. So, it kind of looks like you're holding a pistol, like a fake pistol, when you're clawing, so they had to put a splint together to fix that up which was good. So, I only had to wear that for about three months, and then my fingers got strong enough to stop wearing that but then I had to keep going with my strengthening exercises.
Host: Over a year on from her surgery, and Kat's arm is basically back to normal.
Kat: My arm looks pretty normal now, I have a giant scar I think it's about 12cm long last time I checked. But it is a really clean scar, they did an excellent job. Even the way they did the stitches just blew my mind it was all internal, which I really can’t see how you do that but they did it (laugh). And so, it's not swollen anymore. When I had the tumour, my arm was noticeably swollen in that particular area, so it's gone back to normal which is great. But it just looks like an ordinary hand and an ordinary arm just with a nice line down it as my scar.
So, after the operation I went in for a routine check-up three days later and that's where they change your dressing and check on how the scar and everything is healing. And then you go back in 15 days after the surgery as well and that's when they cut the ends of the stitches off, so they were all dissolvable so they heal internally, and it was at that 15-day mark that they had the diagnosis back to say that it was benign, so there was no cancer, which was really great, I was over the moon about that and my mum was even happier which is great.
Host: While we can't prevent rare tumours like Kat's from growing on our nerves, there are things Queenslanders can do to keep their nerves and nervous system functioning and healthy. Belinda shared her recommendations for a healthy, happy ulnar nerve.
Belinda: So, to protect our ulnar nerve I would suggest thinking about our posture, I talk to patients about imagining that someone takes a photo of them and you're checking in on your posture. So, if you are sitting at your desk, if you're a student taking frequent breaks not sitting for long periods of time with your elbows in a flexed position, looking at your work set-up, looking at how you sleep. Maybe going to see a therapist if you have any concerns.
Eating well and sleeping well are really important for general health, and nerve health is no different. They've done some studies on the importance of vitamin C in relation to looking after your nerves and in nerve recovery, and some of the orthopaedic doctors I work with will routinely prescribe vitamin C at a fairly high level. I would encourage anyone to talk to their pharmacist about what the appropriate level is. There's some evidence that it facilitates recovery of nerve and nerve health. So, making sure if your diet's inadequate that you might need to take a supplement. But otherwise I think getting out and moving well, looking after your posture, looking at your work space are probably the most important things in terms of protecting your nerves and particularly your ulnar nerve.
Host: We also asked Belinda to clear up one of the biggest ulnar nerve questions for us: why is it called the funny bone, when hitting your elbow is clearly not funny at all?
Belinda: So, there are two schools of thought around why the funny bone's called the funny bone; one is its proximity or closeness to the humerus – sounds like humorous, funny – and also other people believe it's because that exquisite sensation of pain and numbness and tingling is supposed to feel ‘funny’ in inverted commas, so I'm not sure which one it is. I err on the side of the second one, I think it feels a bit funny to hit your funny bone.
Host: Whether it got the nickname funny bone from a clever pun or because of it's not-so-funny sensitivity when you bump it, the ulnar nerve is a part of your nervous system and body that plays a huge role in your everyday life. Next time you pick something up, write, type or bump your funny bone, keep in mind the complex workings of your nervous system, from thought to nervous system response, to the triggering of the muscles in your hand.
Host: Thanks for joining us for another episode of My Amazing Body. My Amazing Body is brought to you by Queensland Health. With special thanks to our expert guest Belinda Bond, patient Kat and my podcast colleagues: Lauren our researcher, writer and producer; Carol our audio technician; Dan our music guru; and the media team at West Moreton Hospital and Health Services.