What type of imaging is warranted for a patient with unrelenting lateral epicondylitis (tennis elbow)?

Imaging for Unrelenting Tennis Elbow (Lateral Epicondylitis)

For unrelenting tennis elbow, radiographs should be obtained as initial imaging, followed by MRI if symptoms persist, as MRI shows high inter- and intraobserver reliability with 90-100% sensitivity and 83% specificity for confirming epicondylalgia. 1, 2

Initial Imaging Approach

• Radiographs (X-rays) are the appropriate first-line imaging for chronic elbow pain, including lateral epicondylitis 1
• Radiographs can identify potential causes of pain such as intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis 1
• Comparison with the asymptomatic side is often useful for better evaluation 1

Advanced Imaging Options (When Radiographs Are Normal or Nonspecific)

MRI Elbow

• MRI is the preferred advanced imaging for unrelenting tennis elbow with high diagnostic accuracy 2
• MRI demonstrates high inter- and intraobserver reliability with 90-100% sensitivity and 83% specificity for epicondylalgia 1
• Most specific MRI findings include intermediate to high T2 signal within the common extensor tendon and paratendinous soft tissue edema 1
• MRI can also identify associated findings such as radial collateral and lateral ulnar collateral ligament injuries that may contribute to persistent symptoms 1
• MRI facilitates surgical planning when conservative management fails 1

Ultrasound Examination

• Ultrasound shows moderate agreement with MRI for diagnosing common extensor tendon tears (sensitivity 64.25%, specificity 85.19%) 2
• Advanced ultrasound techniques have improved diagnostic accuracy:
  • Sonoelastography shows promising outcomes with sensitivity 95.2%, specificity 92% 1
  • Combination of superb microvascular imaging with conventional ultrasound performs best (sensitivity 94%, specificity 98%) 1

When to Consider Other Imaging Modalities

• CT arthrography or CT elbow: Consider when suspecting loose bodies, heterotopic ossification, or osteophytosis (sensitivity 93%, specificity 66% for loose bodies) 1
• 3-Phase bone scan: Limited evidence for routine use in tennis elbow, but can detect chronic epicondylalgia when other imaging is inconclusive 1
• MR arthrography: Does not add additional information compared to standard MRI for epicondylalgia 1

Clinical Considerations and Pitfalls

• Persistent symptoms despite negative initial imaging should prompt consideration of advanced imaging 2
• Pain may be referred from cervical spine pathology or radial tunnel syndrome, requiring further investigation when provocative tests are negative 2
• In refractory cases, MRI can identify specific pathology (such as granulation tissue with high T2 signal) that may guide surgical intervention 3
• Failure to identify underlying pathology with appropriate imaging may lead to continued symptoms and disability despite conservative treatment 3