71-year-old male with bilateral lateral elbow pain for more than 18–24 months. Symptoms fluctuate and worsen with loading, gripping, wrist extension, sport, or work-related activity. Previous conservative or interventional treatments have not provided sustained improvement.
Ultrasound examination of both lateral elbows demonstrates tendinopathic changes of the common extensor tendon, consistent with chronic lateral elbow tendinopathy.
On the right side, the common extensor tendon shows degenerative tendinopathic change with an intratendinous calcification measuring 6.92 × 4.68 mm. Doppler examination demonstrates very mild neovascularization.
On the left side, the common extensor tendon also shows tendinopathic change with an intratendinous calcification measuring 7.41 × 2.63 mm. In addition, a fluid collection is visible, most likely communicating with or originating from the elbow joint. There is also suspicion of a small partial lesion of the lateral collateral ligament complex.
There is no evidence of a complete rupture of the common extensor tendon on either side. The overall appearance is consistent with long-standing chronic degenerative tendon pathology, in keeping with the prolonged and load-dependent clinical course.
1. Final diagnosis
Bilateral chronic calcific tendinopathy of the common extensor tendon, consistent with chronic lateral elbow tendinopathy or tennis elbow. On the right side, there is calcific tendinopathy with very mild neovascularization. On the left side, there is calcific tendinopathy with an additional joint-related fluid collection and suspicion of a small partial lesion of the lateral collateral ligament complex.
2. Differential diagnosis
The primary diagnosis is bilateral chronic lateral elbow tendinopathy with calcific degenerative or entheseal changes of the common extensor tendon. A partial degenerative tear within the common extensor tendon may be considered, particularly in the setting of long-standing symptoms and persistent load intolerance. On the left side, an additional intra-articular or ligamentous pain source should be considered, such as synovial irritation, radiocapitellar degenerative change, a synovial recess or ganglion, plica-related irritation, or a small partial lesion of the lateral collateral ligament complex.
3. Teaching points
Chronic lateral elbow tendinopathy may show tendon thickening, hypoechogenicity, loss of the normal fibrillar pattern, calcification, and variable Doppler neovascularization. Bilateral abnormalities should always be interpreted in relation to symptoms, loading history, work demands, sport activity, and possible referred pain from the cervical spine or shoulder region. A joint-related fluid collection or suspected lateral collateral ligament abnormality, as seen on the left side in this case, may indicate an additional intra-articular or ligamentous component beyond isolated tendinopathy.
4. Injury/disease information
Lateral elbow tendinopathy is a chronic overload-related disorder of the common extensor tendon, most often involving the extensor carpi radialis brevis origin. It is commonly associated with repetitive gripping, lifting, wrist extension, racket sports, manual work, or sustained computer-related loading. Management is usually based on load modification, ergonomic adaptation, and progressive strengthening of the wrist extensors, grip function, and proximal kinetic chain. In chronic therapy-resistant cases, ultrasound-guided interventions or specialist reassessment may be considered, especially when calcifications, suspected partial tearing, joint fluid, or possible ligament involvement are present.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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