Ultrasound of Lateral Epicondylitis

Abstract

Clinical findings are generally sufficient to make the diagnosis of lateral epicondylitis of the elbow. Ultrasound (US), in conjunction with standard radiography, is a simple and cost-effective way to confirm the diagnosis, and it is also useful for eliminating most differential diagnoses and guiding treatment.

US analysis of the muscle bodies and tendon laminae of the lateral epicondyle muscles, starting distally at the wrist and extending up to the lateral epicondyle, assists in understanding the complex fibrous architecture of the proximal tendons inserting on the lateral epicondyle. Pain when the US probe passes over an area of hypoechoic tendinosis, hyperemia in Doppler mode, and an intratendinous split are the signs to look for in patients. US helps guide needling or injection by targeting pathologic areas.

Other examinations (computed tomography arthrogram and magnetic resonance imaging) are used as a second line of defense, particularly in cases of bone or joint pathology.

Keywords

elbow - anatomy - ultrasound - tendon - lateral epicondylitis

Publication History

Article published online:
19 November 2024

• References

• 1 Tosti R, Jennings J, Sewards JM. Lateral epicondylitis of the elbow. Am J Med 2013; 126 (04) 357.e1-357.e6
• 2 Pasternack I, Tuovinen EM, Lohman M, Vehmas T, Malmivaara A. MR findings in humeral epicondylitis. A systematic review. Acta Radiol 2001; 42 (05) 434-440
• 3 Maylack FH. Epidemiology of tennis, squash, and racquetball injuries. Clin Sports Med 1988; 7 (02) 233-243
• 4 Morris H. Lawn-tennis elbow. BMJ 1883; 2 (1185): 556-558
• 5 Kamina P. Muscles de l'avant-bras. In: Kamina P. ed. Anatomie Clinique. Vol 1. Paris, France: Maloine; 2007: 224-239
• 6 Netter FH. Elbow and forearm. In: Netter FH. ed. Netter Atlas of Human Anatomy: Classic Regional Approach. 8th ed.. Philadelphia, PA: Elsevier; 2023. plates 446–461
• 7 Paulsen F, Waschke J. Upper extremity, muscle of the forearm. In: Paulsen F, Waschke J. eds. Sobotta Atlas of Human Anatomy with Latin Nomenclature. Vol 1. 15th ed.. Stuttgart, Germany: Urban and Fischer; 2011: 180-185
• 8 Omoumi P, Gondim Teixeira PA, Ward SR, Trudell D, Resnick D. Practical ultrasonographic technique to precisely identify and differentiate tendons and ligaments of the elbow at the level of the humeral epicondyles: anatomical study. Skeletal Radiol 2021; 50 (07) 1369-1377
• 9 Brasseur JL, Jacob D. Echographie de la face latérale du coude. In: Echographie du coude. Paris, France: Sauramps Medical; 2020: 89-120
• 10 Lapegue F, Andre A. Écho-anatomie des épicondyliens latéraux [in French] [Dissection and echoanatomy of the lateral epicondyle muscles]. YouTube video. 2023. Available at: https://www.google.fr/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjCtuba1c6EAxV9TaQEHWx4CSE4ChC3AnoECAgQAg&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D0Lu25tP900g&usg=AOvVaw1_9BqPlHiBOI6iT-HTQGAy&opi=89978449 Accessed September 12, 2024
• 11 Konarski W, Poboży T. A clinical overview of the natural course and management of lateral epicondylitis. Orthopedics 2023; 46 (04) e210-e218
• 12 Johns N, Shridhar V. Lateral epicondylitis: current concepts. Aust J Gen Pract 2020; 49 (11) 707-709
• 13 Yang X, Ying L, Ying L, Zhang Q, Han D, Zhou X. Modified arthroscopic tenotomy of the extensor carpi radialis brevis for refractory lateral epicondylitis: a cohort study. J Shoulder Elbow Surg 2024; 33 (03) 536-543
• 14 Dones III VC, Grimmer K, Thoirs K, Suarez CG, Luker J. The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review. BMC Med Imaging 2014; 14: 10
• 15 Krogh TP, Fredberg U, Ammitzbøl C, Ellingsen T. Ultrasonographic characteristics of the common extensor tendon of the elbow in asymptomatic individuals: thickness, color Doppler activity, and bony spurs. Orthop J Sports Med 2017; 5 (05) 2325967117704186
• 16 Ustabaşıoğlu F, Günay B, Samancı C, Emre Ustabaşıoğlu F. Assessment of common extensor tendon vascularization using superb microvascular imaging: a potential tool in the evaluation of extracorporeal shock wave therapy and therapeutic ultrasound effectiveness in lateral epicondylitis. Acta Radiol 2023; 64 (10) 2828-2835
• 17 Rupe MW, Fleury IG, Glass N, Kruse R, Buckwalter V JA. Efficacy of ultrasonic tenotomy and debridement and platelet-rich plasma injections for lateral elbow tendinopathy. J Hand Surg Glob Online 2023; 5 (05) 667-672
• 18 Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics 2010; 30 (01) 167-184
• 19 Bonczar M, Ostrowski P, Dziedzic M. et al. Evaluation of lateral epicondylopathy, posterior interosseous nerve compression, and plica syndrome as co-existing causes of chronic tennis elbow. Int Orthop 2023; 47 (07) 1787-1795
• 20 Bal E, Cetin O. Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis. Medicine (Baltimore) 2023; 102 (40) e35499
• 21 Qi L, Zhang YD, Yu RB, Shi HB. Magnetic resonance imaging of patients with chronic lateral epicondylitis: is there a relationship between magnetic resonance imaging abnormalities of the common extensor tendon and the patient's clinical symptom?. Medicine (Baltimore) 2016; 95 (05) e2681
• 22 Ikeda K, Ogawa T, Ikumi A. et al. Individual evaluation of the common extensor tendon and lateral collateral ligament improves the severity diagnostic accuracy of magnetic resonance imaging for lateral epicondylitis. Diagnostics (Basel) 2022; 12 (08) 1871
• 23 Kessler RE, Day MS, Tyler TF. et al. Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis. JSES Int 2022; 6 (02) 305-308
• 24 Ang BFH, Mohan PC, Png MA. et al. Ultrasonic percutaneous tenotomy for recalcitrant lateral elbow tendinopathy: clinical and sonographic results at 90 months. Am J Sports Med 2021; 49 (07) 1854-1860
• 25 Suzuki T, Hayakawa K, Nakane T, Fujita N. Repeated magnetic resonance imaging at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. J Shoulder Elbow Surg 2022; 31 (08) 1581-1587
• 26 Sharma GK, Patil A, Kaur P, Rajesh S, Drakonaki E, Botchu R. Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis—a randomised controlled trial. J Ultrasound 2024; 27 (02) 315-321
• 27 Dakkak M, Patel V, King D, Genin J. Ultrasound-guided tenotomy for lateral epicondylitis with TenJet improves physical functional and decreased pain outcomes at 1 year: a case series review. JSES Int 2023; 7 (05) 872-876
• 28 Edelson G, Kunos CA, Vigder F, Obed E. Bony changes at the lateral epicondyle of possible significance in tennis elbow syndrome. J Shoulder Elbow Surg 2001; 10 (02) 158-163