Compressive neuropathy of the ulnar nerve at the elbow is a common problem, and many acute cases resolve with nonoperative treatment. Before considering operative treatment for chronic cases, the surgeon must consider differential diagnoses and must localize the lesion to the elbow. The type of procedure chosen depends on many factors. There is a paucity of good comparative studies in the literature to aid the surgeon in selection of the most effective procedure. The surgical treatment must be tailored to each case after determining the cause of the neuropathy and after examining patient factors, such as occupation, activity level, and coexisting systemic conditions. Often, the type of surgery performed is the one with which the surgeon has the most experience and is most comfortable. Recurrent problems most often are due to failure to relieve the true source of compression at the original procedure. Repeat exploration to address all potential areas of compression, with subsequent submuscular transposition, is effective in most of these difficult cases.