Investigation Requirements for Tennis Elbow
Tennis elbow (lateral epicondylitis) is primarily a clinical diagnosis that typically does not require imaging or laboratory investigations in straightforward cases. 1, 2
Clinical Diagnosis Approach
The diagnosis should be established through:
- History: Lateral elbow pain exacerbated by wrist extension and supination, often related to repetitive occupational or athletic activities
- Physical examination: Specific clinical tests including:
When Imaging IS Indicated
According to the 2022 ACR Appropriateness Criteria, radiographs are beneficial as initial imaging for chronic elbow pain when you need to rule out alternative diagnoses 3. Specifically, plain radiographs can identify:
- Intra-articular bodies
- Heterotopic ossification
- Osteochondral lesions
- Soft tissue calcification
- Occult fractures
- Osteoarthritis 3
Advanced Imaging Considerations
MRI, CT, and other advanced modalities have limited evidence supporting their use as initial imaging for uncomplicated lateral epicondylitis 3. These should be reserved for:
- Atypical presentations requiring exclusion of other pathology
- Suspected intra-articular pathology when radiographs are normal or nonspecific 3
- Pre-surgical planning in refractory cases
Critical Differential Diagnoses to Consider
A thorough understanding of alternative causes of lateral elbow pain is imperative to prevent unnecessary testing 2:
- Cervical radiculopathy
- Radial tunnel syndrome or other entrapment neuropathies
- Osseous pathology
- Inflammatory arthropathies 1
If nerve symptoms are present (numbness, tingling), electromyography may be appropriate to evaluate for nerve-related pathology 3.
Common Pitfall
The most common error is ordering unnecessary imaging for typical presentations of lateral epicondylitis. Since 90% of cases are self-limiting 1, and the condition responds well to conservative management, routine imaging adds cost without changing initial management in most patients. Reserve imaging for cases where the diagnosis is uncertain, symptoms are atypical, or conservative treatment has failed and surgical intervention is being considered.