Should I order an X-ray (radiograph) for a patient with golfer's elbow (medial epicondylitis)?

X-ray for Golfer's Elbow (Medial Epicondylitis)

Radiographs (X-rays) are beneficial and appropriate as the initial imaging for patients with golfer's elbow (medial epicondylitis) 1, 2.

Diagnostic Approach for Golfer's Elbow

Initial Imaging

• X-rays are the most appropriate first-line imaging modality for all elbow pain, including medial epicondylitis 1, 2
• Benefits of initial radiographs:
  • May reveal intra-articular bodies, heterotopic ossification, soft tissue calcification, occult fracture, or osteoarthritis 1
  • Help rule out other causes of medial elbow pain
  • Serve as a baseline for comparison if advanced imaging is needed later
  • Comparison with the asymptomatic side is often useful 1

When to Order Advanced Imaging

Advanced imaging should be considered only when:

• Symptoms persist beyond 3 months despite appropriate conservative treatment 2
• X-rays are normal or nonspecific but clinical suspicion for other pathology remains high 1
• MRI is the gold standard for evaluating tendinous injuries (extra-articular) 2

Clinical Considerations

Differential Diagnosis

Radiographs help rule out other causes of medial elbow pain, including:

• Cervical radiculopathy (C6-C7), which has been associated with medial epicondylitis in over half of patients 3
• Medial collateral ligament injury
• Cubital tunnel syndrome
• Intra-articular pathology

Treatment Algorithm

1. Initial phase (0-6 weeks):

   • Begin with X-ray to establish baseline and rule out other pathologies
   • Conservative management: rest, ice, NSAIDs, eccentric strengthening exercises, bracing 2, 4

2. Intermediate phase (6-12 weeks):

   • If symptoms persist, consider corticosteroid injection (limit to 1-2 injections)
   • Continue eccentric exercises 2

3. Persistent symptoms (>3 months):

   • Reassess diagnosis with advanced imaging (MRI) 2
   • Consider referral to orthopedic surgeon if symptoms persist despite 6+ months of conservative management 2, 4

Important Caveats

• Medial epicondylitis affects 1% of the general population but 3.8% to 8.2% of work-related complaints 5
• While diagnosis can be made based on clinical examination alone, imaging is essential for confirmation and excluding other pathologies 6
• Ultrasound has high sensitivity (95%) and specificity (92%) for diagnosing medial epicondylitis and can be an alternative to MRI, but its diagnostic efficacy depends on operator experience 6
• Approximately 80% of epicondylitis cases resolve with conservative treatment 7

Remember that while X-rays are appropriate initial imaging, they primarily help rule out other conditions rather than directly confirming medial epicondylitis, which is primarily a clinical diagnosis.