Ulnar nerve injury after radial extracorporeal shock wave therapy identified with high–resolution ultrasonography: Case Report.

Lesión del nervio cubital secundario a terapia de ondas de choque extracorpóreas radiales identificada con ultrasonografía de alta resolución: Reporte de caso.





ulnar neuropathy, extracorporeal shockwave therapy, medial epicondylitis, ultrasonography, case report


A 49-year old woman was evaluated for developing bilateral acute medial elbow pain, numbness, and tingling sensation in the fourth and fifth fingers after receiving radial extracorporeal shock wave therapy (rESWT) for bilateral medial epicondylitis. Neurologic examination revealed the presence of Tinel’s sign, paresthesia and impaired two-point discrimination testing over the ulnar side of the fourth and fifth fingers bilaterally. High-resolution ultrasonography demonstrated findings of nerve injury, such as hypoechogenicity and increased diameter of both ulnar nerves.  After conservative treatment, the patient improved her condition demonstrating an apparently acute compressive nerve injury as a result of the therapy. ESWT is used as a promising alternative for the treatment of various musculoskeletal disorders; however, there is limited evidence regarding its side effects, in particular peripheral mononeuropathy. To the authors’ knowledge, this is the first report demonstrating structural damage of a nerve after rESWT with the use of high-resolution ultrasonography.


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1. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015; 23: 348-355. https://www.ncbi.nlm.nih.gov/pubmed/26001427

2. Moya, Daniel & Ramon, Silvia & Schaden, Wolfgang & Wang, Ching-Jen & Guiloff, Leonardo & Cheng, Jai-Hong. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. JBJS 2018; 100: 251.

3. Shim JS, Chung SG, Bang H, Lee HJ, Kim K. Ulnar neuropathy after extracorporeal shockwave therapy: a case report. PMR 2015; 7: 667-70.

4. Wang, Ching-Jen. Extracorporeal shockwave therapy in musculoskeletal disorders. Journal of orthopaedic surgery and research. 2012; 7: 1186.

5. Dingemanse, Rudi & Manon, Soubde & Koes, Bart & Huisstede, Bionka. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: A systematic review. BJSPORTS. 2013; 10: 1136.

6. Consensus Statement on ESWT Indications and Contraindications. ISMST. October 12th, 2016. https://www.shockwavetherapy.org/fileadmin/user_upload/dokumente/PDFs/Formulare/ISMST_consensus_statement_on_indications_and_contraindications_20161012_final.pdf. October 12th, 2016.

7. Seok Lee, Sang & Kang, Sangkuk & Kyoung Park, Noh & Woo Lee, Chan & Sup Song, Ho & Kyun Sohn, Min & Cho, kang Hee & Hwan Kim, Jung. Effectiveness of Initial Extracorporeal Shock Wave Therapy on the Newly Diagnosed Lateral or Medial Epicondylitis. Annals of rehabilitation medicine. ARM. 2012; 36: 681.

8. Turhan, Yalcin & Arican, Mehmet & Okan Karaduman, Zekeriya. Clinical and functional outcomes of extracorporeal shock wave therapy in isolated medial epicondylitis. The European Research Journal 2019; 5(4): 658-662.

9. M, Haake & R Böddeker, I & T, Decker & M, Buch & M, Vogel & G, Labek & Maier, Maresa & Loew, Markus & O, Maier-Boerries & J, Fischer & Betthäuser, A & C Rehack, H & W, Kanovsky & Müller, I & Gerdesmeyer, Ludger & Rompe, Jan. Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow. Archives of orthopaedic and trauma surgery. 2002; 10: 1007.

10. Furia, John & Rompe, Jan & Cacchio, Angelo & Maffulli, Nicola. Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures. Foot and ankle clinics 2010; 15(4): 651-662.

11. B Barco, Raul & Antuña, Samuel. Medial elbow pain. EFORT Open Rev. 2017; 2 (8): 362-371.

12. Menorca RMG, Fussell TS, Elfar JC. Peripheral nerve trauma: mechanisms of injury and recovery. Hand Clin. 2013; 29: 317–330.

13. Tapadia, Minal & Mozaffar, Tahseen & Gupta, Ranjan. Compressive Neuropathies of the Upper Extremity: Update on Pathophysiology, Classification, and Electrodiagnostic Findings. The Journal of hand surgery. 2010; 35: 668-77.

14. Hausdorf J, Lemmens MA, Heck KD, et al. Selective loss of unmyelinated nerve fibers after extracorporeal shockwave application to the musculoskeletal system. Neuroscience 2008; 155: 138-144.

15. Schelling G, Delius M, Gschwender M, Grafe P, Gambihler S. Extracorporeal shock waves stimulate frog sciatic nerves indirectly via a cavitation-mediated mechanism. Biophys J 1994; 66: 133-140.

16. Dy C, Mackinnon S. Ulnar neuropathy: Diagnosis and management. Curr Rev Musculoskelet Med. 2016; 9: 178–84.

17. Macchi, Veronica & Tiengo, Cesare & Porzionato, Andrea & Stecco, Carla & Sarasin, Gloria & Tubbs, R. Shane & Maffulli, Nicola & De Caro, Raffaele. The cubital tunnel: A radiologic and histotopographic study. Journal of anatomy. JOA. 2014; 10: 225

18. Campbell WW, Carroll C, Landau ME. Ulnar neuropathy at the elbow. Five new things Neurology. 2015; 5: 135–141.

19. Beekman, Roy & Schoemaker, Mc & P L Van Der Plas, J & H Van Den Berg, L & Franssen, H & Wokke, J.h.j & M J Uitdehaag, B & Visser, Leo H. Diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow. Neurology. 2004; 62: 767-73.

20. Suk JI, Walker FO, Cartwright MS. Ultrasonography of peripheral nerves. Curr Neurol Neurosci Rep. 2013; 13: 328.

21. Deniel, A & Causeret, A & Moser, Thomas & Rolland, Yan & Dréano, T & Guillin, Raphaël. Entrapment and traumatic neuropathies of the elbow and hand: An imaging approach. Diagnostic and Interventional Imaging. 2015; 10: 1006.

22. E Landau, Mark & W Campbell, William. Clinical Features and Electrodiagnosis of Ulnar Neuropathies. Physical medicine and rehabilitation clinics of North America. 2013; 24: 49-66.

23. Pais P, Fodor D, Fisher T. Bilateral cubital tunnel syndrome: Case report with review of the literature. Med Ultrasonogr. 2009; 11: 31-36.

24. Navarro E. Síndromes compresivos del nervio cubital en codo y muñeca. Medigraphic org. 2014; 10: 26.

25. Checkles NS, Russakov AD, Piero DL. Ulnar nerve conduction velocity—effect of elbow position on measurement. Arch Phys Med Rehabil 1971; 53: 362.

26. Shik Yoon, Joon & O Walker, Francis & Cartwright, Michael. Ulnar neuropathy with normal electrodiagnosis and abnormal nerve ultrasound. Arch Phys Med Rehabil. 2010; 91(2): 318–320.

27. Bismil QMK, Bismil MSK. Cubital tunnel syndrome with false-negative nerve conduction studies treated with wide awake ulnar nerve decompression via the OSWA pathway. OA Case Reports 2013; 12: 113.



How to Cite

Terán, P. G., Insuasti, W. E., Martínez, D. M., Platero, T. M., Ramos, S. G., & Llocclla, S. (2020). Ulnar nerve injury after radial extracorporeal shock wave therapy identified with high–resolution ultrasonography: Case Report.: Lesión del nervio cubital secundario a terapia de ondas de choque extracorpóreas radiales identificada con ultrasonografía de alta resolución: Reporte de caso. Revista De La Facultad De Medicina Humana, 20(2), 1. https://doi.org/10.25176/RFMH.v20i2.2912