Imaging Guidelines for Diagnosing Tennis Elbow

Initial Imaging Approach

The American College of Radiology recommends plain radiographs of the elbow as the appropriate initial imaging study for evaluating lateral epicondylitis, though the diagnosis remains predominantly clinical 1.
Radiographs help exclude alternative diagnoses including fractures, heterotopic ossification, osteoarthritis, soft tissue calcification, and osteochondral lesions 1, 2.
Comparison views with the contralateral asymptomatic elbow can be useful to identify asymmetry 1.

The American College of Radiology suggests MRI as the preferred imaging modality for chronic elbow pain when radiographs are normal or nonspecific and symptoms persist despite conservative management 1.
MRI provides superior soft tissue characterization and can identify tendon pathology, associated ligamentous injuries, nerve compression (radial tunnel syndrome), and other soft tissue abnormalities 1.

The American College of Radiology states that CT imaging (with or without contrast) has no established role in the initial or routine evaluation of lateral epicondylitis 3, 1.
The American College of Radiology also notes that three-phase bone scan is not supported as an imaging study for tennis elbow evaluation 3, 1.
MR arthrography and CT arthrography are reserved for suspected intra-articular pathology (loose bodies, osteochondral lesions) rather than lateral epicondylitis 1.

For atypical features, trauma history, or failed conservative treatment, the American College of Radiology recommends obtaining plain radiographs to exclude alternative diagnoses 1, 2.
For persistent symptoms after 6-12 weeks of appropriate conservative management with normal radiographs, consider MRI to evaluate for alternative diagnoses including radial tunnel syndrome, ulnar neuropathy, or occult pathology 1.