Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation.

Department of Radiology, McMaster University, Hamilton, ON, Canada.
Skeletal Radiology (Impact Factor: 1.74). 12/2011; 41(4):369-86. DOI: 10.1007/s00256-011-1343-8
Source: PubMed

ABSTRACT The diagnosis of lateral epicondylitis is often straightforward and can be made on the basis of clinical findings. However, radiological assessment is valuable where the clinical picture is less clear or where symptoms are refractory to treatment. Demographics, aspects of clinical history, or certain physical signs may suggest an alternate diagnosis. Knowledge of the typical clinical presentation and imaging findings of lateral epicondylitis, in addition to other potential causes of lateral elbow pain, is necessary. These include entrapment of the posterior interosseous and lateral antebrachial cutaneous nerves, posterolateral rotatory instability, posterolateral plica syndrome, Panner's disease, osteochondritis dissecans of the capitellum, radiocapitellar overload syndrome, occult fractures and chondral-osseous impaction injuries, and radiocapitellar arthritis. Knowledge of these potential masquerades of lateral epicondylitis and their characteristic clinical and imaging features is essential for accurate diagnosis. The goal of this review is to provide an approach to the imaging of lateral elbow pain, discussing the relevant anatomy, various causes, and discriminating factors, which will allow for an accurate diagnosis.

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    ABSTRACT: Study Design Case report. Background Addressing weakness of the shoulder region, especially the rotator cuff and scapular musculature is often suggested clinically for the treatment of individuals with lateral epicondylalgia. However, to our knowledge, the clinical effectiveness of this approach has not been established. Case Description The patient was a 54 year old female with a 5 month history of right lateral elbow pain whose symptoms were reproduced with clinical tests typically used to diagnose lateral elbow tendinopathy. The patient also demonstrated weakness in her middle and lower trapezius muscles and the medial border of her scapula, measured with a tape measure, was 11 cm lateral from the spinous processes of the thoracic spine with the patient standing in relaxed stance. Based on improved grip strength and reduced associated elbow pain when tested with the scapula manually corrected in a more adducted position, treatment focused solely on strengthening of the middle and lower trapezius muscles over a 10 week period. Outcomes Following the intervention, the patient presented with improved scapular position with the medial border of the scapula being 9 cm lateral to the mid-thoracic spine. Middle and lower trapezius strength improved from 3+/5 and 4-/5 respectively to 5/5, and grip strength from 26.1 to 42.2 kg. Disabilities of the Arm, Shoulder and Hand (DASH) scores also improved from 44.1at the initial evaluation to 0 at the completion of therapy with the patient being able to perform all of her daily activities in a pain free manner. Discussion The results of this case report suggest that assessment and treatment of scapular musculature warrants consideration in the management of individuals with lateral epicondylalgia. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther, Epub 9 September 2013. doi:10.2519/jospt.2013.4659.
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    ABSTRACT: OBJECTIVE. The objective of our study was to investigate the clinical feasibility of ultrasound elastography for assessing patients with lateral epicondylosis and to establish an objective and quantitative method of elastographic measurement in the affected tendon. SUBJECTS AND METHODS. A total of 97 symptomatic and 89 asymptomatic common extensor tendons from both elbows of 79 consecutive patients with lateral epicondylosis and 14 healthy participants were prospectively examined by gray-scale sonography, color Doppler sonography, and compression-based elastography. Real-time color-coded elastography was performed and quantified with two regions of interest: the adjacent subcutis (S1) for a reference area and the common extensor tendon (S2) for the target area. The mean strain ratio (S1/S2) was used for quantitative comparisons. The difference in the mean strain ratio between symptomatic and asymptomatic tendons was assessed with conditional regression analysis. RESULTS. In symptomatic elbows, 87 of 97 tendons (89.7%) showed intratendinous hypoechogenicity, 86 of 97 (88.7%) showed swelling, and 70 of 97 tendons (72.2%) showed intratendinous hyperemia. Color-coded elastography revealed a soft area on 73 of 97 tendons (75.3%). The mean strain ratio was 1.45 (SD, 0.45) for symptomatic tendons and 2.07 (SD, 0.70) for asymptomatic tendons. The mean strain ratio of the symptomatic tendons was significantly lower than that of asymptomatic tendons (p < 0.001), indicating that the symptomatic tendons were softer. CONCLUSION. Our results revealed that patients with lateral epicondylosis had significantly lower strain ratios in their common extensor tendon origins. Ultrasound elastography using quantitative strain ratio measurements could be a promising supplementary method to evaluate tendon abnormalities in lateral epicondylosis.
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    ABSTRACT: Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments.The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE. Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel. Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (Kappa > 0.8). A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators.
    BMC Musculoskeletal Disorders 10/2013; 14(1):310. · 1.90 Impact Factor