The Predictive Value of Diagnostic Sonography for the Effectiveness of Conservative Treatment of Tennis Elbow

Defining tennis elbow characteristics - The assessment of magnetic resonance imaging defined tendon pathology in an asymptomatic population

Background

This radiological study aims to assess the prevalence of lateral elbow pathology in an asymptomatic population using 3.0T magnetic resonance imaging (MRI).

Methods

Bilateral elbow MRI was undertaken in 30 asymptomatic volunteers. Exclusion criteria included elbow pain within 3 months, elbow trauma or previous diagnosis of lateral epicondylar tendinopathy. Baseline patient-reported outcome measures were recorded along with age and body mass index (BMI). Two musculoskeletal radiologists independently graded the degree of abnormality at the common extensor tendon.

Results

Thirty volunteers were categorised according to age; 35-44 (n = 10), 45-54 (n = 11), and 55-65 (n = 9) with a 1:1 male-to-female ratio. Radiological evidence of tendon abnormality was found in 37% of volunteers. The proportion with abnormal findings increased with age; 35-44 (10%), 45-54 (36%), 55-65 (67%) and BMI; 18-24.9 (23%), 25-29.9 (43%), > 30 (67%). Changes were generally 'mild' or 'moderate', with a single volunteer showing 'severe' pathology. Kappa for the radiographic agreement was 0.91 (0.83-0.98).

Discussion

This study has demonstrated MRI findings suggestive of pathology at the common extensor tendon to be prevalent in an asymptomatic population, increasing with age and BMI. This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients.

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

Comparing the efficacy of continuous and pulsed ultrasound therapies in patients with lateral epicondylitis: A double-blind, randomized, placebo-controlled study

Objectives

The aim of this study was to investigate the efficacy of continuous and pulsed ultrasound therapies in lateral epicondylitis.

Patients and methods

A total of 51 patients (18 males, 33 females; mean age: 46.52±6.16 years; range, 27 to 64 years) who were diagnosed with lateral epicondylitis between February 2013 and October 2014 were included. The patients were randomized to either continuous ultrasound (n=17), pulsed ultrasound (n=17), or placebo (n=17) groups. First group received 10 sessions of continuous ultrasound therapy. The second group received 10 sessions of pulsed ultrasound therapy in a ratio of 1:4. The third group received 10 sessions of placebo treatment. The pain levels of the patients were evaluated using Visual Analog Scale (VAS). The muscle strength was evaluated using a dynamometer. For functional evaluation, Duruöz’s Hand Index (DHI) and Patient-Rated Tennis Elbow Evaluation (PRTEE) scales were used. Assessments were made at baseline, at the end of therapy, and one month after therapy. The thickness of the common extensor tendon was also measured using ultrasonic imaging at baseline and at the end of therapy.

Results

At the end of the study, there was a statistically significant improvement in the rest and activation VAS scores, and DHI and PRTEE scores in both continuous and pulsed ultrasound therapy groups, compared to placebo (p<0.05). However, no superiority was found between the continuous and pulsed ultrasound therapy groups (p>0.05). A statistically significant reduction in the common extensor tendon thickness was found only in the pulsed ultrasound therapy group (p<0.05).

Conclusion

Our study results show that both continuous and pulsed ultrasound applications are effective in the treatment of lateral epicondylitis.

Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) - A systematic review

BACKGROUND

Reviews on the diagnostic performance of the examination tests for lateral elbow tendinopathy (LET) based on updated context-specific tools and guidelines are missing.

PURPOSE

To review the diagnostic accuracy of examination tests used in LET.

DESIGN

Systematic review following PRISMA-DTA guidelines.

METHODS

We searched MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, and Cochrane Library databases. The QUADAS-2 checklist was used to assess the methodological quality of the eligible studies. We included diagnostic studies reporting the accuracy of physical examination tests or imaging modalities used in patients with LET.

RESULTS

Twenty-four studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies). Most studies (97%) were assessed with "unclear" or "high risk" of bias. Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%). Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%). MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%). The Cozen's test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%).

CONCLUSIONS

Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated. USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment and reference standards across the studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020160402.

Ultrasonographic analysis of the extensor carpi radialis brevis in asymptomatic individuals

BACKGROUND

Tennis elbow is characteristically seen as damage at the extensor carpi radialis brevis (ECRB) on ultrasonography. In this study, damage at the origin of the ECRB was investigated using ultrasonography in elbows without complaints pertaining to the joint.

METHODS

We investigated 282 elbows on the dominant side in volunteers who consented to participate in the study and had no complaints or history of trauma to either elbow, no tenderness in the lateral epicondylar region on physical examination, and no pain upon resisted extension of the wrist and/or middle finger with the elbow extended (162 men, 120 women; mean age 62 years, range 21-84 years). On ultrasonography, damage at the origin of the ECRB was defined as low echo or disruption in fiber orientation. Comparison between groups with and without damage was performed based on age, sex, history of sports activity involving the upper extremity, and history of work involving loading of the upper extremity.

RESULTS

Of the 282 elbows, damage was noted in 60 (21.3%). Comparing the groups with and without damage, mean ages were 66.2 (40-80) years and 60.9 (21-84) years. The group with damage included 31 of 162 (18.1%) male elbows and 29 of 110 (26.4%) female elbows; 10 of 64 elbows (15.6%) had a positive history of sports involving the upper extremity and 50 of 218 elbows (22.9%) had no history; 16 of the 64 elbows (25.0%) had a positive history of work involving loading the upper extremity and 44 of the 218 elbows (20.2%) had no history. Age was significantly higher in the group with damage. The group with damage showed no significant differences in other categories.

CONCLUSIONS

Asymptomatic damage at the ECRB origin was noted in 21.3% of elbows at higher ages, but there was no association with sports or work.

Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis Versus Asymptomatic Healthy Controls

BACKGROUND

Ultrasonography (US) is often used in the assessment of lateral epicondylitis (LE). The strength of evidence supporting its role is, however, not well-documented.

PURPOSE

To describe and compare the US tendinopathic changes observed in patients with LE and the general population, including any correlation between patient characteristics and US outcomes.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Tendon thickness, color Doppler activity, and bone spur were assessed by US in 264 participants with healthy elbows and 60 patients with chronic LE. In addition to patient characteristics, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, pain, and disability were recorded.

RESULTS

Depending on the measurement technique used, mean LE tendon thickness increased by 0.53 mm (10.2%) or 0.70 mm (14.5%) as compared with the contralateral arm and 0.40 mm (7.9%) or 0.41 mm (8.5%) as compared with the general population. Mean color Doppler activity (scale, 0-4) was 3.47 in the LE arm versus 0.13 in the contralateral asymptomatic arm and 0.26 in the general population. Bone spur was observed in 78% of the LE arms as opposed to 45% in the contralateral arms and 50% in the general population. In the LE group and the general population, the prevalence of bone spur increases with age. No correlations were observed with pain, disability, PRTEE, and disease duration.

CONCLUSION

Increased common extensor tendon thickness is part of the tendinopathic changes observed in LE. However, given the marked variation in natural tendon thickness and small increases in tendon thickness in patients with LE, this technique cannot be used as a stand-alone diagnostic tool but rather as a supplement to the overall assessment. The contralateral elbow (if asymptomatic) is a better tendon thickness comparator than a general population mean value. Color Doppler activity is an indicator of ongoing tendinopathy and supports the LE diagnosis, but it is not pathognomonic for the condition. Absence of Doppler activity in a patient with suspected LE should raise suspicion of other diagnoses. Identification of a bone spur is of very limited clinical value given the high prevalence in the general population. The important outcomes of pain, disability, PRTEE, and disease duration did not correlate with any of the investigated US techniques.

Diagnostic Accuracy of Echo Envelope Statistical Modeling Compared to B-Mode and Power Doppler Ultrasound Imaging in Patients With Clinically Diagnosed Lateral Epicondylosis of the Elbow

OBJECTIVES

To compare the accuracy of homodyned K quantitative ultrasound (QUS) with that of B-mode and Doppler ultrasound imaging for discriminating between lateral epicondylosis (LE) and asymptomatic elbows.

METHODS

This prospective study received Institutional Review Board approval, and participants provided written informed consent. Between February 2015 and March 2017, 30 LE elbows in 27 patients and 24 asymptomatic elbows in 13 volunteers underwent B-mode, Doppler, and radiofrequency ultrasound imaging of the common extensor tendon (CET) and radial collateral ligament (RCL). Two readers classified the elbows independently on the basis of a review of B-mode and Doppler images. The global and local estimates of QUS parameters (μ _n , 1/α, and k) were computed in the CET and CET-RCL regions, respectively, and the area of each region was calculated. A random-forest classifier identified the most discriminating 3-parameter combination: CET global estimate of 1/α, CET-RCL area, and local estimate of k.

RESULTS

The patients with LE had a mean age of 50 years (range, 31-66 years), and the volunteers had a mean age of 50 years (range, 37-57 years). The area under the receiver operating characteristic curve, sensitivity, and specificity of reader 1, reader 2, and the QUS-based model were 0.80 (95% confidence interval [CI], 0.66-0.95), 0.72 (95% CI, 0.56-0.89), and 0.88 (95% CI, 0.72-1.04); 0.79 (95% CI, 0.66-0.93), 0.65 (95% CI, 0.47-0.82), and 0.84 (95% CI, 0.67-1.01); and 0.82 (95% CI, 0.80-0.85), 0.73, and 0.79, respectively.

CONCLUSIONS

An automated, computer-based QUS technique diagnosed LE with accuracy of 0.82. This technique could provide quantitative biomarkers for the characterization of LE disease.

Predictors of Outcome Following Tenotomy in Patients with Recalcitrant Epicondylopathy

BACKGROUND

Elbow tendinopathies are associated with tenderness, pain, and functional disability with ensuing socioeconomic costs. There is lack of consensus regarding the best treatment for patients recalcitrant to first-line conservative treatments. Percutaneous needle tenotomy is considered a regenerative approach that injures the tendon to elicit a healing response.

OBJECTIVE

To investigate whether demographic characteristics, clinical factors, baseline sonographic entities, or their interactions are related to the likelihood of responding positively to needle tenotomy over a 1-year follow-up period.

DESIGN

Prospective case series.

SETTING

Tertiary institutional hospital.

PARTICIPANTS

Patients with elbow tendinopathy for whom conservative treatments had failed and who had persistent symptoms lasting for at least 3 months.

METHODS

Patients underwent needle tenotomy with or without PRP followed by a lighter needle tenotomy within a 2-week interval as part of treatment.

MAIN OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder and Hand (DASH) and Visual Analogue Scale for pain (VAS-P) scores were assessed before intervention (baseline) and at 6 weeks and 3, 6, and 12 months after intervention. A generalized linear mixed effects model was created to examine whether injectate type, clinical, demographic, or pretreatment sonographic entities or their interactions influenced clinical outcomes.

RESULTS

The authors analyzed 74 elbows (71 patients). At baseline, analyzed patients (mean age: 49.48 years; 51.35% women) scored 43.30 and 5.83 on the DASH and VAS-P, respectively. Pretreatment tendon vascularization was a predictor of pain (P = .011) and DASH score changes (P = .019). The linear mixed effect model revealed that male gender and hypercholesterolemia were associated with enhanced functional recovery, (P = .020 and P < .001, respectively). Moreover, the interactions between pretreatment vascular status (P = .039), echotexture (P = .037) and enthesophytes (P = .028) influenced the temporal pattern of functional recovery after needle tenotomy.

CONCLUSIONS

Baseline patient characteristics, such as gender and hypercholesterolemia, along with ultrasound features may be predictive of outcomes following needle tenotomy for elbow tendinopathy.

LEVEL OF EVIDENCE

IV (NCT01945528).

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE

To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

RESULTS

We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

DISCUSSION

Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.

Ultrasonographic Evaluation of the Radial Nerves in Patients with Unilateral Refractory Lateral Epicondylitis

Objective

To evaluate the possible radial nerve entrapment of patients with unilateral refractory lateral epicondylitis (LE) by using ultrasound (US) and electroneuromyography.

Design

Cross-sectional study.

Setting

Three physical medicine and rehabilitation departments.

Subjects

Consecutive 44 patients (15 M, 29 F) with unilateral refractory LE.

Methods

All patients underwent detailed clinical, electrophysiological and ultrasonographic evaluations. Ultrasound imaging was used to evaluate thickness and presence of abnormal findings of the common extensor tendon (CET) and cross-sectional area (CSA) of the radial nerve (at spiral groove and before bifurcation) bilaterally. Unaffected sides of the patients were taken as controls.

Results

When compared with the unaffected sides, CET thickness and radial nerve CSAs (at both levels) were higher, and abnormal US findings regarding LE (47.7% vs. 6.8%) were more common on the affected sides than nonaffected sides (all P  < 0.001). Grip strength values were lower on the affected sides ( P  < 0.001). Electrophysiological studies were all normal, and similar between the two sides (all P  > 0.05). When subgroup analyses were performed after taking into account the hand dominance, affected and dominant sides were found to be the same in 31 and different in 13 patients. In subgroups, CETs and radial nerve CSAs at both levels were higher on the affected sides (all P  < 0.01).

Conclusions

Radial nerves and the CETs seem to be swollen on the affected sides, independent from the hand dominance of the patients with refractory LE. These results morphologically support the previous literature that attributes some of the chronic complaints of these patients actually to radial nerve entrapment.

Ultrasonographic Evaluation of Acupuncture Effect on Common Extensor Tendon Thickness in Patients with Lateral Epicondylitis: A Randomized Controlled Study

OBJECTIVE

To explore the effect of acupuncture on common extensor tendon (CET) thickness in patients with lateral epicondylitis (LE). Additionally, to identify whether clinical and ultrasonographic changes showed any correlation.

METHODS

Forty-one patients were randomly assigned to acupuncture and control groups. Conventional treatment (rest, NSAİİ, bracing, exercise) methods for LE were applied to all patients. In addition to this, the acupuncture treatment was applied to the acupuncture group. The visual analog scale (VAS) for pain, the Duruoz Hand Index (DHI) for functioning of the affected limb, the pressure pain threshold, and CET thickness (via ultrasound imaging) were assessed before and end of the treatment in both groups.

RESULTS

The VAS and DHI scores in both groups decreased. The pressure pain threshold and CET thickness only demonstrated improvement in the acupuncture group.

CONCLUSION

These findings show that the CET thickness was reduced after 10 sessions of acupuncture treatment in LE patients.

Comparison of Therapeutic Effect of Extracorporeal Shock Wave in Calcific Versus Noncalcific Lateral Epicondylopathy

Objective

To assess the therapeutic effect of extracorporeal shock wave therapy (ESWT) in lateral epicondylopathy with calcification, and compare it to the effect of ESWT in lateral epicondylopathy without calcification.

Methods

A retrospective study was conducted. Forty-three patients (19 with calcific and 24 with noncalcific lateral epicondylopathy in ultrasound imaging) were included. Clinical evaluations included the 100-point score, Nirschl Pain Phase scale before and after ESWT, and Roles and Maudsley (R&M) scores after ESWT. ESWT (2,000 impulses and 0.06–0.12 mJ/mm²) was performed once a week for 4 weeks.

Results

The 100-point score and Nirschl Pain Phase scale changed significantly over time (p<0.001), but there was no significant difference between groups (p=0.555). The R&M scores at 3 and 6 months after ESWT were not significantly different between groups. In the presence of a tendon tear, those in the calcific lateral epicondylopathy group showed poor improvement of 100-point scores compared to the noncalcific group (p=0.004).

Conclusion

This study demonstrated that the therapeutic effect of ESWT in calcific lateral epicondylopathy was not significantly different from that in noncalcific lateral epicondylopathy. When a tendon tear is present, patients with calcific lateral epicondylopathy might show poor prognosis after ESWT relative to patients with noncalcific lateral epicondylopathy.

Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin

BACKGROUND

This study investigated the factors associated with variation in the rate of surgery for enthesopathy of the extensor carpi radialis brevis (eECRB).

METHODS

We used a large database from 3 academic hospitals including 5964 patients with the diagnosis of eECRB from 2001 to 2007. Of those, 244 patients (4%) had surgery for eECRB. We used the date of the first encounter as the date of diagnosis. We also recorded the date of the first cortisone injection and surgery for eECRB. We used Cox multivariable regression analysis to find factors associated with surgery. We considered the following explanatory factors: age, sex, race, diabetes, a diagnosis of major depression, a diagnosis of an anxiety disorder, hospital, provider (surgeon vs. nonsurgeon), corticosteroid injection, and the time from diagnosis to the first cortisone injection.

RESULTS

The hazard ratio of having surgery was 12-times greater if the initial provider was an orthopedic surgeon rather a nonsurgeon and 1.7-times greater at 1 of the 2 hospitals. The rate of surgery varied substantially, ranging from 0% to 22%. Corticosteroid injection delayed the time to surgery but was ultimately associated with a higher rate of surgery. The majority (86%) of surgeries were done within 1 year of the first documented office visit.

CONCLUSIONS

It seems likely that an emphasis on the preferences and values of the patient rather than the surgeon would decrease the variation in surgery rates for eECRB observed in this study. Methods for optimizing the influence of patient preferences and values on decision making (eg, decision aids) merit additional study.

The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis

BACKGROUND

The purpose of this study was to determine the diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis.

METHODS

An electronic search of databases registering published (MEDLINE, EMBASE, CINAHL, AMED, Cochrane Library, ScienceDirect) and unpublished literature was conducted to January 2013. All diagnostic accuracy studies that compared the accuracy of ultrasound (index test) with a reference standard for lateral epicondylitis were included. The methodological quality of each of the studies was appraised using the QUADAS tool. When appropriate, the pooled sensitivity and specificity analysis was conducted.

RESULTS

Ten studies investigating 711 participants and 1077 elbows were included in this review. Ultrasound had variable sensitivity and specificity (sensitivity: 64%-100%; specificity: 36%-100%). The available literature had modest methodological quality, and was limited in terms of sample sizes and blinding between index and reference test results.

CONCLUSIONS

There is evidence to support the use of ultrasound in the detection of lateral epicondylitis. However, its accuracy appears to be highly dependent on numerous variables, such as operator experience, equipment and stage of pathology. Judgement should be used when considering the benefit of ultrasound for use in clinical practice. Further research assessing variables such a transducer frequency independently is specifically warranted.

LEVEL OF EVIDENCE

Level II.

The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review

Background

Ultrasound is considered a reliable, widely available, non-invasive and inexpensive imaging technique for assessing soft tissue involvement in Lateral epicondylalgia. Despite the number of diagnostic studies for Lateral Epicondylalgia, there is no consensus in the current literature on the best abnormal ultrasound findings that confirm lateral epicondylalgia.

Methods

Eligible studies identified by searching electronic databases, scanning reference lists of articles and chapters on ultrasound in reference books, and consultation of experts in sonography. Three reviewers (VCDIII, KP, KW) independently searched the databases using the agreed search strategy, and independently conducted all stages of article selection. Two reviewers (VCDIII, KP) then screened titles and abstracts to remove obvious irrelevance. Potentially relevant full text publications which met the inclusion criteria were reviewed by the primary investigator (VCDIII) and another reviewer (CGS).

Results

Among the 15 included diagnostic studies in this review, seven were Level II diagnostic accuracy studies for chronic lateral epicondylalgia based on the National Health and Medical Research Council Hierarchy of Evidence. Based from the pooled sensitivity of abnormal ultrasound findings with homogenous results (p > 0.05), the hypoechogenicity of the common extensor origin has the best combination of diagnostic sensitivity and specificity. It is moderately sensitive [Sensitivity: 0.64 (0.56-0.72)] and highly specific [Specificity: 0.82 (0.72-0.90)] in determining elbows with lateral epicondylalgia. Additionally, bone changes on the lateral epicondyle [Sensitivity: 0.56 (0.50-0.62)] were moderately sensitive to chronic LE. Conversely, neovascularity [Specificity: 1.00 (0.97-1.00)], calcifications [Specificity: 0.97 (0.94-0.99)] and cortical irregularities [Specificity: 0.96 (0.88-0.99)] have strong specificity for chronic lateral epicondylalgia. There is insufficient evidence supporting the use of Power Doppler Ultrasonogrophy, Real-time Sonoelastography and sonographic probe-induced tenderness in diagnosing LE.

Conclusions

The use of Gray-scale Ultrasonography is recommended in objectively diagnosing lateral epicondylalgia. The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. In addition to diagnosis, detection of these abnormal ultrasound findings allows localization of pathologies to tendon or bone that would assist in designing an appropriate treatment suited to patient’s condition.

Utility of sonographic measurement of the common tensor tendon in patients with lateral epicondylitis

OBJECTIVE

The purpose of this article is to evaluate prospectively the utility of sonographic measurements of the common extensor tendon for diagnosing lateral epicondylitis.

SUBJECTS AND METHODS

Forty-eight patients with documented lateral epicondylitis and 63 healthy volunteers were enrolled and underwent ultrasound of the elbow joint. The common extensor tendon overlying the bony landmark was scanned transversely, and the cross-section area and the maximum thickness were measured. Clinical examination was used as the reference standard in the diagnosis of lateral epicondylitis. Data from the patient and control groups were compared with established optimal diagnostic criteria for lateral epicondylitis using receiver operating characteristic curves. Qualitative evaluation with grayscale ultrasound was also performed on patients and healthy volunteers.

RESULTS

The common extensor tendon was significantly thicker in patients with lateral epicondylitis than in control subjects (p < 0.01). Tendon thickness greater than 4.2 mm (sensitivity, 78.4%; specificity, 95.2%; accuracy, 87.7%) and area larger than or equal to 32 mm(2) (sensitivity, 86.3%; specificity, 82.5%; accuracy, 84.2%) were highly predictive of lateral epicondylitis. For qualitative evaluation with gray-scale ultrasound, overall sensitivity, specificity, and accuracy values in the diagnosis of lateral epicondylitis were 76.5%, 76.2%, and 76.3%, respectively.

CONCLUSION

The quantitative sonographic measurements had an excellent diagnostic performance for lateral epicondylitis, as well as good or excellent interreader agreement. A common extensor tendon cross-section area greater than or equal to 32 mm(2) and a thickness of 4.2 mm correlated well with the presence of lateral epicondylitis. However, further prospective study is necessary to determine whether quantitative ultrasound with these cutoff values can improve the accuracy of the diagnosis of lateral epicondylitis.

Sonographic findings for the common extensor tendon of the elbow in the general population

OBJECTIVE

To describe structural characteristics and sonographic alterations of the common extensor tendon (CET).

METHODS

In 240 patients, we determined the body mass index; sonographic CET thickness, morphologic characteristics, and alterations; and color Doppler measurements of the epicondylar artery width and peak systolic velocity. Age, sex, epicondylalgia history, activities (work, sports, and hobbies), and dominant and nondominant elbows were noted.

RESULTS

The CET was thicker in the dominant elbow (4.77 versus 4.61 mm [P = .023]), male patients (dominant, 5.09 versus 4.46 mm [P < .001]; nondominant, 5.00 versus 4.21 mm [P < .001]), patients involved in risk activities (dominant, 5.21 versus 4.70 mm [P < .001]; nondominant, 5.12 versus 4.53 mm [P < .001]), and those with a history of epicondylalgia (right, 5.27 versus 4.70 mm [P < .001]; left, 4.86 versus 4.60 mm [P = .316]). Thickness correlated weakly with age (dominant, r = 0.284; nondominant, r = 0.215) and moderately with weight (dominant, r = 0.492; nondominant, r = 0.502). The mean epicondylar artery diameter was 1.35 mm (SD, 0.96 mm); mean peak velocity, 13.01 cm/s (SD, 4.90 cm/s). Morphologic abnormalities were found in 79.5% of patients with a history of epicondylalgia; 7.7% with no history had abnormalities; and 55.9% with abnormalities but no history were older than 55 years. Bone spurs (49.2% versus 16.4% [P < .001]), tendon calcifications (21.5% versus 3.9% [P < .001]), and bone cortex abnormalities (12.3% versus 1.7% [P < .001]) were found more often in non-normal elbows; 79.4% of bone spurs in normal elbows occurred in patients older than 55 years.

CONCLUSIONS

Mild sonographic alterations in the CET and bone spurs should be considered with caution when assessing epicondylar pain, especially in patients older than 55 years and those with a history of epicondylalgia.

Measurement issues in the sonographic assessment of tennis elbow

Sonography is increasingly being used for assessment in tennis elbow research and clinical practice, but there are a lack of data regarding its validity, reliability, and responsiveness to change for this application. Studies using the modality were reviewed to establish current levels of evidence for these measurement properties. There is reasonable evidence regarding its validity for identifying tennis elbow tendinopathy, but a lack of data addressing its reliability and responsiveness. Practical issues affecting image quality are discussed, and recommendations for further investigation are suggested, to enhance the credible use of sonography with this debilitating condition.

Modern imaging of the hand, wrist, and forearm

A review of the current state of the relevant diagnostic imaging technologies and methods and their clinical application in imaging common conditions of the hand, wrist, and forearm is presented. Evolving and future imaging technologies are also considered.