Background <p>Currently, the primary treatment for ulnar neuropathy at the elbow is open in-situ decompression surgery. The effectiveness of ultrasound localization therapy, especially small-incision surgery using ultrasound combined with SWE, remains unclear.</p> Objectives <p>To evaluate the effect of small-incision ulnar nerve release in treating ulnar neuropathy at the elbow by ultrasound combined with shear wave elastography (SWE).</p> Methods <p>A retrospective analysis of 98 patients treated in our hospital for ulnar neuropathy at the elbow was conducted from June 2023 to March 2025. According to the treatment style, these patients were divided into a traditional open in-situ decompression surgery group (<i>n</i> = 51) and an ultrasound combined with SWE small-incision surgery group (<i>n</i> = 47). The maximum proximal Cross-sectional Area (CSA), Sensory Conduction Velocity (SCV), Motor Conduction Velocity (MCV), modified Bishop score, Quick-DASH score, and Visual Analogue Scale(VAS) score were compared between the two groups. Additionally, the amount of intraoperative blood loss, operation duration, hospital stay, patients' satisfaction with postoperative incision aesthetics, the postoperative complications of different operation methods, and the degree of damage to the medial cutaneous nerve of the forearm were studied.</p> Results <p>All patients underwent surgical treatment, with preoperative ultrasonography confirming no ulnar nerve subluxation. No statistically significant differences in age, preoperative SCV, MCV, CSA, Quick-DASH score, or VAS score were found between the two groups. The postoperative and the last follow-up SCV, MCV, and CSA were similar in the two groups. In addition, the improved Bishop score, Quick-DASH score, VAS score, postoperative hematoma rate, elbow stiffness rate, and postoperative protection of the medial cutaneous nerve of the forearm in the ultrasound combined with SWE surgery group were better than those in the traditional open surgery group. What’s more, compared with the traditional open surgery group, the ultrasound combined with SWE surgery reduced the amount of intraoperative blood loss, shortened the operation duration and hospital stay, and the patients were more satisfied with the scar of the incision.</p> Conclusions <p>For patients with ulnar neuropathy at the elbow who are amenable to in situ decompression, this study highlights the potential of preoperative ultrasound combined with SWE to guide a targeted, minimally invasive surgical approach.</p>