BACKGROUND: Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone. METHODS: A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5-year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment. RESULTS: Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not. CONCLUSIONS: Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.