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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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

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)

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