49-year-old female with lateral right elbow pain related to tennis activity, particularly provoked during the backhand stroke. There is pain and functional limitation during elbow extension, with residual pain following activity.
Ultrasound examination of the lateral elbow demonstrates tendinopathic change at the common extensor tendon origin at the lateral epicondyle.
Within the tendon, there is a moderate partial-thickness tear with disruption of tendon fibers.
Doppler examination demonstrates marked intratendinous and peritendinous neovascularization.
The combination of tendon structural abnormality, partial fiber disruption, and increased Doppler activity is consistent with active symptomatic lateral elbow tendinopathy with associated partial tendon injury.
1. Final diagnosis
Marked lateral elbow tendinopathy involving the common extensor tendon origin, with a moderate partial-thickness tear and pronounced neovascularization. The findings correlate with the clinical diagnosis of lateral epicondylalgia associated with tennis loading.
2. Differential diagnosis
If the degree of extension restriction or deep joint pain is not adequately explained by the tendon abnormality, additional intra-articular elbow pathology should be considered, including radiocapitellar pathology, synovial plica, or other joint abnormalities. In the presence of neurological symptoms, radial nerve or posterior interosseous nerve pathology should also be considered.
3. Teaching points
Lateral epicondylalgia may demonstrate a spectrum of ultrasound abnormalities ranging from tendon thickening and loss of fibrillar architecture to partial-thickness tearing. Doppler neovascularization is a frequent finding in chronic symptomatic tendinopathy but should be interpreted together with tendon morphology and clinical symptoms. In this case, the combination of structural tendon damage and marked Doppler activity supports an active symptomatic tendon process.
4. Injury/disease information
Lateral elbow tendinopathy is commonly associated with repetitive loading of the wrist and finger extensors and may be aggravated by tennis backhand mechanics. Initial management generally consists of relative load reduction without complete immobilization, followed by progressive symptom-guided rehabilitation of the wrist and finger extensors using graded isometric and concentric-eccentric strengthening and a phased return to sport. Corticosteroid injection may provide short-term pain relief but is generally not preferred in chronic tendinopathy with partial tendon damage because longer-term outcomes may be less favorable. If symptoms persist despite an adequately structured rehabilitation program, specialist assessment may be considered. If an invasive procedure such as platelet-rich plasma injection is pursued, ultrasound guidance is appropriate to accurately target the abnormal tendon while accounting for the partial tear. Persistent mechanical locking, marked extension restriction, or disproportionate deep joint pain may warrant MRI to assess for intra-articular pathology.
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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