Lateral Epicondylitis (Tennis Elbow) Surgery Workup

Updated: Apr 10, 2023
  • Author: Brett D Owens, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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Imaging Studies


Radiography is the initial imaging study for chronic elbow pain. Radiographs can be helpful in ruling out other disorders or concomitant intra-articular pathology (eg, osteochondral loose body, posterior osteophytes). Calcification in the degenerative tissue of the extensor carpi radialis brevis (ECRB) origin can be seen in chronic cases. [9]  If radiographs are nondiagnostic, other modalities (eg, magnetic resonance imaging [MRI], computed tomography [CT], ultrasonography [US], and bone scanning) are considered.

Other imaging modalities

A guideline from the American College of Radiology (ACR) outlined appripriate uses of US, CT, CT arthrography, MRI, and magnetic resonance (MR) arthrography in the workup of chronic elbow pain when radiographs are normal or nonspecific, as follows [10] :

  • Mechanical symptoms are present; intra-articular pathology is suspected - MR arthrography, MRI without contrast, CT arthrography, CT without contrast
  • Occult stress fracture or other bone abnormality is suspected - MRI without contrast, CT without contrast, possibly three-phase bone scan
  • Chronic epicondylalgia or tendon tear is suspected; empiric treatment is ineffective - US, MRI without contrast
  • Collateral ligament tear is suspected - US, MR arthrography, MRI without contrast, CT arthrography, possibly radiographic stress views
  • Nerve abnormality is suspected - US, MRI without contrast, possibly CT without contrast



Other Tests

If the clinical examination indicates a possible neural etiology for the patient's symptoms, electromyography (EMG) can be helpful in excluding posterior interosseous nerve compression syndrome as the diagnosis.



Anesthetic injections into the origin of the ECRB can help confirm the diagnosis; patients should experience symptomatic relief with such injections.


Histologic Findings

Despite the implication of the term lateral epicondylitis, the histology of the lesions shows neither acute nor chronic inflammatory cell infiltrate; thus, the term is actually a misnomer. The lesions are characterized by fibroblastic invasion with neovascularization. One study noted mesenchymal cell proliferation indicative of a healing process. However, most other studies indicate degenerative changes. [11]



Nirschl defined the following progressive stages of lateral epicondylitis:

  • Stage 1 - Inflammatory changes that are reversible
  • Stage 2 - Nonreversible pathologic changes to the origin of the ECRB
  • Stage 3 - Rupture of the origin of the ECRB
  • Stage 4 - Secondary changes, such as fibrosis or calcification