OBJECTIVE: The aim of the study is to define a standardized comprehensive sonographic approach for evaluating the different histoanatomical compartments of the lateral elbow. DESIGN: Using high-frequency ultrasound probes, we tried to match the anatomical features of the lateral elbow and its different sonographic patterns in patients with the diagnosis of lateral epicondylitis. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation. RESULTS: Modern ultrasound equipment seems to provide an extremely detailed sonographic assessment of the different anatomical layers located in the lateral compartment of the elbow. Moreover, high-sensitive color/power Doppler imaging allows for clear visualization of the perfusion patterns in pathological conditions. CONCLUSIONS: In clinical practice, high-frequency B-mode and high-sensitive color/power Doppler imaging can be integrated with the clinical findings to better define the pain generator(s) for optimizing the management of patients with lateral epicondylitis.

From the Physical and Rehabilitation Medicine Unit Luigi Sacco University Hospital ASST Fatebenefratelli Sacco Milan Italy

See more in PubMed

Binder AI, Hazleman BL: Lateral humeral epicondylitis—a study of natural history and the effect of conservative therapy. Br J Rheumatol 1983;22:73–6

Ricci V, Özçakar L: From “ultrasound imaging” to “ultrasound examination”: a needful upgrade in musculoskeletal medicine. Pain Med 2020;21:1304–6

Tagliafico AS, Bignotti B, Martinoli C: Elbow US: anatomy, variants, and scanning technique. Radiology 2015;275:636–50

Ricci V, Güvener O, Chang KV, et al.: EURO-MUSCULUS/USPRM dynamic ultrasound protocols for elbow. Am J Phys Med Rehabil 2022;101:e83–92

Nirschl RP, Pettrone FA: Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am 1979;61:832–9

Mullett H, Sprague M, Brown G, et al.: Arthroscopic treatment of lateral epicondylitis: clinical and cadaveric studies. Clin Orthop Relat Res 2005;439:123–8

Ricci V, Ricci C, Gervasoni F, et al.: From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach. Eur J Phys Rehabil Med 2022;58:108–17

Ricci V, Ricci C, Gervasoni F, et al.: From histoanatomy to sonography in myofascial pain syndrome: a EURO-MUSCULUS/USPRM approach. Am J Phys Med Rehabil 2023;102:92–7

Clarke AW, Ahmad M, Curtis M, et al.: Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability. Am J Sports Med 2010;38:1209–14

Greenbaum B, Itamura J, Vangsness CT, et al.: Extensor carpi radialis brevis. An anatomical analysis of its origin. J Bone Joint Surg Br 1999;81:926–9

Schneeberger AG, Masquelet AC: Arterial vascularization of the proximal extensor carpi radialis brevis tendon. Clin Orthop Relat Res 2002;398:239–44

Nirschl RP, Ashman ES: Elbow tendinopathy: tennis elbow. Clin Sports Med 2003;22:813–36

Zeisig E, Ohberg L, Alfredson H: Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthrosc 2006;14:659–63

Spang C, Alfredson H: Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow—implication for treatment? J Musculoskelet Neuronal Interact 2017;17:97–103

Teixeira PA, Omoumi P, Trudell DJ, et al.: Ultrasound assessment of the lateral collateral ligamentous complex of the elbow: imaging aspects in cadavers and normal volunteers. Eur Radiol 2011;21:1492–8

Zoner CS, Buck FM, Cardoso FN, et al.: Detailed MRI-anatomic study of the lateral epicondyle of the elbow and its tendinous and ligamentous attachments in cadavers. AJR Am J Roentgenol 2010;195:629–36

Tsuji H, Wada T, Oda T, et al.: Arthroscopic, macroscopic, and microscopic anatomy of the synovial fold of the elbow joint in correlation with the common extensor origin. Art Ther 2008;24:34–8

Jacobson JA, Chiavaras MM, Lawton JM, et al.: Radial collateral ligament of the elbow: sonographic characterization with cadaveric dissection correlation and magnetic resonance arthrography. J Ultrasound Med 2014;33:1041–8

Sanal HT, Chen L, Haghighi P, et al.: Annular ligament of the elbow: MR arthrography appearance with anatomic and histologic correlation. AJR Am J Roentgenol 2009;193:W122–6

Duparc F, Putz R, Michot C, et al.: The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat 2002;24:302–7

Milz S, Tischer T, Buettner A, et al.: Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis. Ann Rheum Dis 2004;63:1015–21

Wu WT, Chang KV, Hsu YC, et al.: Artifacts in musculoskeletal ultrasonography: from physics to clinics. Diagnostics (Basel) 2020;10:645

Park CH, Kim BS, Lee JH, et al.: Optimal elbow positions for identification of the radial collateral ligament using ultrasonography. PM R 2020;12:671–8

Wee TC, Simon NG: Asymptomatic common extensor tendon pathology in patients with carpal tunnel syndrome. Muscle Nerve 2021;64:64–9

Omoumi P, Gondim Teixeira PA, Ward SR, et al.: Practical ultrasonographic technique to precisely identify and differentiate tendons and ligaments of the elbow at the level of the humeral epicondyles: anatomical study. Skeletal Radiol 2021;50:1369–77

Özçakar L, Kara M, Chang KV, et al.: EURO-MUSCULUS/USPRM basic scanning protocols for elbow. Eur J Phys Rehabil Med 2015;51:485–9

De Maeseneer M, Brigido MK, Antic M, et al.: Ultrasound of the elbow with emphasis on detailed assessment of ligaments, tendons, and nerves. Eur J Radiol 2015;84:671–81

Ricci V, Schroeder A, Özçakar L: Ultrasound imaging for lateral elbow pain: pinpointing the epicondylosis. Am J Phys Med Rehabil 2020;99:560–1

Özçakar L: Sonographic Atlas for Common Musculoskeletal Pathologies . Milan, Edi Ermes, 2017. ISBN: 9788870515763

Potter HG, Hannafin JA, Morwessel RM, et al.: Lateral epicondylitis: correlation of MR imaging, surgical, and histopathologic findings. Radiology 1995;196:43–6

du Toit C, Stieler M, Saunders R, et al.: Diagnostic accuracy of power doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med 2008;42:872–6

Kehl AS, Corr M, Weisman MH: Review: enthesitis: new insights into pathogenesis, diagnostic modalities, and treatment. Arthritis Rheumatol 2016;68:312–22

Arrigoni P, Cucchi D, Luceri F, et al.: Lateral elbow laxity is affected by the integrity of the radial band of the lateral collateral ligament complex: a cadaveric model with sequential releases and varus stress simulating everyday activities. Am J Sports Med 2021;49:2332–40

Ricci V, Mezian K, Cocco G, et al.: Anatomy and ultrasound imaging of the tibial collateral ligament: a narrative review. Clin Anat 2022;35:571–9

Arrigoni P, Cucchi D, D’Ambrosi R, et al.: Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc 2017;25:2255–63

Ricci V, Becciolini M, Özçakar L: Ultrasound imaging for recalcitrant lateral elbow pain: radio-humeral synovial plica is also at play. Pain Med 2020;21:875–8

Ricci V, Özçakar L: Ultrasound-guided intra-articular injection of the elbow: targeting deep to anconeus muscle. Pain Med 2020;21:3242–3

Tamborrini G, Bruyn GA: CME sonography 93: ultrasound of the enthesis—not every “enthesitis” signals a spondyloarthritis [in German]. Praxis (Bern 1994) 2020;109:888–96

Gandjbakhch F, Terslev L, Joshua F, et al.: Ultrasound in the evaluation of enthesitis: status and perspectives. Arthritis Res Ther 2011;13:R188

Terenzi R, Karalilova R, Lepri G, et al.: Enthesopathy and involvement of synovio-entheseal complex in systemic sclerosis: an ultrasound pilot study. Rheumatology (Oxford) 2020;59:580–5

Krogh TP, Fredberg U, Ammitzbøll C, et al.: Clinical value of ultrasonographic assessment in lateral epicondylitis versus asymptomatic healthy controls. Am J Sports Med 2020;48:1873–83

Ultrasonography for Injecting (Around) the Lateral Epicondyle: EURO-MUSCULUS/USPRM Perspective