Ulnar nerve compression at the elbow is commonly accepted as the second most frequent compressive peripheral neuropathy. The unique anatomic location of the ulnar nerve directly posterior to the medial epicondyle at the elbow places it at risk for injury. With normal motion of the elbow, the ulnar nerve is subjected to compression, traction, and frictional forces. Compression can occur at any of the 5 sites that begin proximally at the arcade of Struthers and end distally where the nerve exits the flexor carpi ulnaris in the forearm. Initial treatment of compressive neuropathy is nonoperative, usually consisting of rest, modification, and/or restriction of elbow or wrist movement. If symptoms persist, especially when accompanied by muscle weakness, surgery is usually indicated. Surgical options include decompression in situ, medial epicondylectomy, transposition of the ulnar nerve (subcutaneous, intramuscular, or submuscular), and/or a combination of these procedures. Careful decompression with a subtotal medial epicondylectomy is a valuable procedure that allows decompression at all levels with minimal risk of devascularizing the nerve or creating elbow instability.