Lateral Epicondylitis (Tennis Elbow) Surgery Workup

Updated: Jun 21, 2021
  • Author: Brett D Owens, MD; Chief Editor: S Ashfaq Hasan, MD  more...
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Workup

Imaging Studies

Radiography

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

MRI can help confirm the presence of degenerative tissue in the ECRB origin and can help diagnose concomitant pathology. A guideline from the American College of Radiology (ACR) recommended MRI as the most appropriate imaging study for patients with suspected chronic epicondylitis when radiographs are nondiagnostic, [10] with US of the elbow a reasonable alternative to MRI if expertise is available.

MRI or magnetic resonance (MR) arthrography is also recommended by the ACR in the following situations when radiographs are nondiagnostic [10] :

  • Mechanical symptoms suggest an intra-articular osteocartilaginous body or synovial abnormality (noncontrast CT of the elbow and CT arthrography of the elbow are alternatives)
  • An occult fracture or other bone abnormality is suspected
  • Assessment of the stability of an osteochondral injury is required (CT arthrography of the elbow is an alternative)
  • A soft-tissue mass is palpable (US of the elbow is an alternative)
  • A collateral ligament tear is suspected
  • A biceps tendon tear is suspected (US of the elbow is an alternative)
  • A nerve abnormality is suspected (US of the elbow is an alternative)
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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.

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Procedures

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

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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]

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Staging

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
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