What type of x-ray (radiograph) is recommended for a patient with golfer's elbow (medial epicondylitis)?

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

Radiographs (X-rays) are recommended as the initial imaging modality for patients with medial epicondylitis (golfer's elbow) to rule out other causes of medial elbow pain and establish a baseline for comparison if advanced imaging becomes necessary. 1

Rationale for X-ray Imaging in Medial Epicondylitis

X-rays serve several important purposes in the evaluation of golfer's elbow:

• Help identify alternative causes of elbow pain including:

  • Intra-articular bodies
  • Heterotopic ossification
  • Soft tissue calcification
  • Occult fractures
  • Osteoarthritis 1

• Provide baseline imaging for comparison if symptoms persist and advanced imaging becomes necessary 1

• Comparison with the asymptomatic side is often useful for detecting subtle abnormalities 1

When to Consider Advanced Imaging

While X-rays are the recommended initial imaging study, they may not always be sufficient. Consider advanced imaging when:

• X-rays are normal or nonspecific but clinical suspicion for pathology remains high 1
• Symptoms persist despite 3+ months of appropriate conservative management 1
• Surgical intervention is being considered 1

MRI is the preferred advanced imaging modality for evaluating tendon and ligamentous injuries of the elbow with high sensitivity and specificity 2, 3. Ultrasound is also a practical alternative to MRI with reported sensitivity and specificity of 95% and 92%, respectively, though its diagnostic efficacy depends heavily on operator experience 3.

Important Clinical Considerations

Radiographic Findings

While radiographs are recommended, it's important to note that they may not always show significant findings in medial epicondylitis:

• Calcification along the lateral epicondyle is seen in only about 7-16% of cases 4, 5
• In one study of 294 radiographs of patients with lateral epicondylitis, only 2 cases (less than 1%) had findings that altered management 5

Treatment Implications

Despite the limited yield of positive findings, radiographs remain important to:

1. Exclude other pathologies that may mimic epicondylitis
2. Establish a baseline before initiating treatment
3. Guide treatment decisions if symptoms persist

Management Algorithm

1. Initial Evaluation: Obtain standard radiographs (anteroposterior, lateral, and radiocapitellar views)
2. If radiographs normal: Proceed with conservative management (rest, activity modification, NSAIDs, eccentric strengthening exercises)
3. If radiographs show alternative pathology: Treat accordingly
4. If symptoms persist >3 months despite conservative treatment: Consider advanced imaging (MRI preferred)
5. If surgical intervention being considered: MRI is recommended to evaluate the extent of tendon pathology 1

Remember that while radiographs are recommended as the initial imaging study, the diagnosis of medial epicondylitis remains primarily clinical, with imaging serving to rule out alternative diagnoses rather than confirm the condition itself.