Diagnostic Imaging for Lateral Epicondylitis

Primary Recommendation: Ultrasound

The American College of Radiology recommends ultrasound as usually appropriate for evaluating suspected tendon or ligament injury when radiographs are normal or indeterminate, which directly applies to lateral epicondylitis, a tendinopathy of the common extensor tendon origin 1
Ultrasound demonstrates moderate to good diagnostic accuracy with sensitivity of 64.25%, specificity of 85.19%, and overall accuracy of 72.73% for diagnosing and grading common extensor tendon tears 1, 2

Advanced US techniques, such as sonoelastography, achieve sensitivity of 95.2%, specificity of 92%, and accuracy of 93.5% for diagnosing lateral epicondylitis 1
Superb microvascular imaging combined with conventional US performs best with sensitivity of 94%, specificity of 98%, and accuracy of 96% for diagnosing lateral epicondylitis 1

There is limited evidence supporting CT or CT arthrography for detecting tendon tears or chronic epicondylalgia, and these modalities are not recommended as alternatives to MRI for lateral epicondylitis 1, 2
Bone scan has limited evidence for routine use in epicondylalgia, though it can detect chronic epicondylalgia in some cases 2

Imaging should be reserved for cases where clinical tests are inconclusive, symptoms persist despite appropriate treatment, or surgical planning is being considered 1
The diagnosis typically involves the dominant arm in 75% of cases and results from repetitive occupational or athletic activities involving wrist extension and supination

Do not order CT for lateral epicondylitis evaluation as it provides no useful information about tendon pathology 1, 2
Remember that US is operator-dependent - ensure the examination is performed by someone experienced in musculoskeletal ultrasound 1

Lateral epicondylitis (tennis elbow) is a common overuse tendon problem affecting the lateral aspect of the elbow, occurring 7-10 times more frequently than medial epicondylitis and typically involving the dominant arm in 75% of cases 3
The American Academy of Family Physicians notes that lateral epicondylitis typically involves the dominant arm in 75% of cases 3

The American College of Radiology recommends that when clinical tests are inconclusive or symptoms persist despite treatment, imaging may be warranted 4
The American College of Radiology suggests that ultrasound or MRI without IV contrast is usually appropriate as the next imaging study after normal or indeterminate radiographs when tendon or ligament injury is suspected 4
Ultrasound has moderate agreement with MRI for diagnosing common extensor tendon tears (sensitivity 64.52%, specificity 85.19%, accuracy 72.73%) 5

The extensibility and pain response of the common extensor tendon under stretch can be evaluated using Mill's test 4