Epicondylitis causes pain and functional impairment and typically results from specific occupational and sports-related activities. Plane selection is important when evaluating the common flexor and extensor tendons and requires proper training of MR imaging technologists. These measures are followed by a rehabilitation program aimed at gradually increasing power, flexibility, and endurance with eventual reintroduction into the implicated sport or occupational activity (7). Notice also the fragmentation as seen on the axial image. Medial Epicondylitis; Incidence. Clinical history: 40 12 months antique male wood worker with lateral elbow ache. (a) Coronal GRE MR image obtained in a 40-year-old woman demonstrates a full-thickness tear and retraction of the ECRB with adjacent edema (arrow). Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis. Knowledge of the typical imaging features of epicondylitis and associated injuries, as well as those of other common sources of elbow pain, allows the radiologist to accurately characterize the pathologic process and guide the referring clinician toward an appropriate treatment plan. Medial and lateral epicondylitis in the athlete. Viewer, Clinical Application of Real-Time Sonoelastography for Evaluation of Medial Epicondylitis: A Pilot Study, Comparision of the efficacy of neural therapy versus steroid injection in the treatment of lateral epicondylitis (tennis elbow), Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements, Ultrasound-guided percutaneous bone drilling for the treatment of lateral epicondylitis, Management of Epicondylitis and Epitrochleitis, The effect of corticosteroid versus platelet-rich plasma injection therapies for the management of lateral epicondylitis: A systematic review, Relationship of cytokine levels and clinical effect on platelet-rich plasma-treated lateral epicondylitis, Extensor tendinopathy of the elbow assessed with sonoelastography: histologic correlation, Sonographic Visualization of the Posterior Cutaneous Nerve of the Forearm: Technique and Validation Using Perineural Injections in a Cadaveric Model, Pathologies of the shoulder and elbow affecting the overhead throwing athlete, Injection of tennis elbow: Hit and miss? MRI . The condition is widely believed to originate from repetitive overuse with resultant microtearing and progressive degeneration due to an immature reparative response. It has been reported that 5% of those with an initial diagnosis of lateral epicondylitis have radial tunnel syndrome (18). The deep radial branches form the posterior interosseus nerve which penetrates the supinator muscle at the arcade of Frohse (arrow). Plain radiographs, including anteroposterior, lateral, and oblique views of the elbow, are frequently obtained and usually are normal. 3rd ed. (a) Coronal GRE MR image obtained in a 40-year-old woman demonstrates a full-thickness tear and retraction of the ECRB with adjacent edema (arrow). 6, 30 September 2014 | Archives of Orthopaedic and Trauma Surgery, Vol. Lateral and medial epicondylitis are common disorders affecting the upper extremity. Here another case. Figure 12 Normal lateral elbow. A tear can also occur in a fall on the outstretched hand. Proton density–weighted fat-saturated MR image obtained in a 57-year-old man demonstrates avulsion of the common extensor tendon, RCL, and LUCL (arrow), with high signal intensity indicative of fluid in the gap between these structures and the lateral epicondyle (*). 56, No. Radial tunnel syndrome involves entrapment of the posterior interosseous nerve (a deep branch of the radial nerve) within the radial tunnel. In the lateral epicondylar region, this process affects the common extensor tendon; in the medial epicondylar region, the common flexor tendon is affected. A positive result of both of these tests is defined as elicitation of focal pain along the MCL. If you cannot make a specific diagnosis, just call the mass indeterminate an do a biopsy, because in many cases you cannot tell the diagnosis. 11, 24 May 2013 | British Journal of Sports Medicine, Vol. Viewer The gray-white discoloration of the tendon is indicative of degeneration. 3, Archives des Maladies Professionnelles et de l'Environnement, Khirurgiya. Epidemiology It is less common than lateral epicondylitis. Since that early description, the designation of little league elbow has expanded to include a host of abnormalities that affect the throwing e… Annular ligament Notice on the T1W-image that there is no atrophy. There is partial tearing, but it is very extensive. This structure on the lateral side of the joint is sometimes seen and is a plica. Fracture of the anteromedial facet of the coronoid process with injuries to the anterior and posterior bundles of the ulnar collateral ligament and to the lateral ligaments, consistent with varus posteromedial rotatory instability of the elbow (PMRI). Here we see images of a patient after repair who did not do so well. This is the counterpart of the lateral epicondylitis and also known as the golfer's elbow. 4, No. Compression on the lateral side causes an osteochondral lesion of the capitellum. Notice how it firmly attaches to the sublime tubercle and compare this to the next images. As we go distally we'll see that they merge together to attach to the sublime tubercle. Here the hole in the capitellum is filled with four pieces of bone and cartilage. There is gadolinium in between the humerus and the osteochondral lesion which indicates that it is unstable. The MCL is also prone to concurrent injury with medial epicondylitis (9,11,22). GOLFER’S ELBOW (MEDIAL EPICONDYLITIS) Golfer’s elbow, or medial epicondylitis, is a form of tendinitis that causes pain and inflammation where the tendons of your forearm muscles attach to the bony bump on the inside of the elbow. However, abnormal changes in the flexor carpi ulnarisand palmaris longus origins at the elbow may also be present. The radial collateral ligament should be assessed to detect periligamentous edema or frank tearing. Again this was diagnosed as indeterminate. Most medial knee injuries are isolated and occur in young active patients participating in sports.1Knowledge of the anatomy and patterns of injury of these structures is crucial for early and correct diagnosis by clinical examination and magnetic resonance (MR) imaging. Epicondylitis occurs due to damage to the tendons in the forearm. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? The fibers of the accessory ligament originate from the annular ligament and insert on the supinator crest, along the lateral aspect of the ulna. Throwing athletes who have repetitive valgus stress on the elbow and repetitive flexor forearm musculature pull develop an overuse syndrome that affects the medial common flexor origin. Coronal GRE MR images obtained in a 30-year-old man show a normal RCL coursing from the radial head to insert on the lateral epicondyle (arrow in a) and an intact LUCL posterior to the radial head (arrow in b). Figure 13 Mild epicondylitis. 47, No. Viewer They run done to the sublime tubercle and a graft is placed in between them. MCL injury, specifically anterior band injury, is included in the differential diagnosis of medial elbow pain, and therefore the MCL must be evaluated. The lesion was located at the insertion of a latissimus dorsi tendon to the humerus (yellow arrow). Coronal GRE MR images obtained in a 30-year-old man show a normal RCL coursing from the radial head to insert on the lateral epicondyle (arrow in a) and an intact LUCL posterior to the radial head (arrow in b). Viewer 1, Ultrasound in Medicine & Biology, Vol. Figure 3 Radial tunnel syndrome. Medial epicondylitis is a consequence of acute or chronic loads applied to the flexor–pronator mass of the forearm as a result of activity related to the medial elbow and proximal forearm. The degenerated portion of the tendon was subsequently excised, the flexor carpi radialis–pronator teres interval was closed, and the intact portion of the tendon was reattached to the medial epicondyle.Figure 33Download as PowerPointOpen in Image The fibers of the RCL course distally along the long axis of the radial head to blend with the fibers of the annular ligament. Viewer This can be explained if we look at the articular surface of the olecranon. It courses distally, parallel to the long axis of the ulna, appearing as a low-signal-intensity band on MR images obtained with any sequence (Fig 20). Medial and lateral epicondylitis in the athlete. It is the result of repetitive impaction and shear forces. Then holes are drilled in the capitellum and the defects are filled with the autologous bone and cartilage. Scroll through the axial images of the biceps tendon from the musculotendinous junction to the attachment on the radial tuberositas. (b) Sagittal STIR MR image shows a central region with the signal intensity of fluid in the proximal common extensor fibers, with a surrounding rim of intermediate signal intensity (arrow), findings consistent with a partial-thickness tear and tendinosis. Attaches at the medial epicondyle. Lateral and medial epicondylitis are two of the more common diagnoses and often occur as … Medial Plantar Proper Digital Neuropathy ... Stoller DW, ed. Surgical techniques include open and arthroscopic approaches with dissection, release, and débridement of the degenerated tendon (1,4,8). The axial image on the upper right shows a mass more proximally in the supinator muscle. There is no recognized gender predilection. Our Team; Our Radiologists; Testimonials; Contact Us; Web Clinic Sign Up; Our Mission . Tenderness is elicited by palpation of the insertion of the flexor-pronator mass (5–10 mm distal and anterior to the middle aspect of the medial epicondyle) (9). Lateral epicondylitis is also known as the tennis elbow, although in 95% of cases it is seen in non-tennis players. Viewer. 38, No. 196, No. Notice that the anterior bundle is much thicker (white arrow). The T2W-fatsat image shows marrow edema and maybe there is a subchondral fracture. Advances in understanding of the anatomy and pathophysiology of epicondylitis have shaped current treatment practices. First study the bones and then continue with the ligaments and the tendons and then the surrounding structures. Ofcourse the T2-fatsat images will show marrow abnormalities, but T1 can be helpful in telling us what is really going on. The radial nerve can be best identified at the level of the radial head, where you can see superficial and deep branches in the radial tunnel (arrows). FCR = flexor carpi radialis, FCU = flexor carpi ulnaris, FDS = flexor digitorum superficialis, PL = palmaris longus, PT = pronator teres.Figure 17Download as PowerPointOpen in Image The prescribed coronal plane is oriented parallel to a line drawn along the anterior surface of the condyles in the axial plane, and the sagittal plane is perpendicular to that coronal plane. Medial Epicondylitis. At arthroscopy there is depression and irregularity of the cartilage of the capitellum. Here are sagittal and axial images of a patient who was referred to an orthopedic oncology surgeon for a mass near the elbow. However, with a confounding clinical picture or with refractory cases, imaging is recommended. Originates at the lateral epicondyle. The common extensor tendon originates at the lateral epicondyle. Now here is the last case. Longitudinal US image of the common flexor origin in a 72-year-old man shows a tendon tear that is near full thickness, with distal linear foci of calcium deposition (black arrows) and marked heterogeneity at the musculotendinous junction (white arrow).Figure 32Download as PowerPointOpen in Image Axial T2-weighted fast SE (a) and sagittal STIR (b) MR images obtained in a 30-year-old man demonstrate a normal appearance of the common flexor tendon (arrow), which originates as a band with uniformly low signal intensity on the anteromedial aspect of the medial epicondyle. This patient is a little bit older. Typically, the extensor carpi radialis brevis is the component that is involved. The pain is caused by damage to the tendons that bend the wrist toward the palm. It is thought that repetitive stress and overuse lead to tendinosis with microtrauma and partial tearing that may progress to a full-thickness tendon tear (1–3). 44, No. Magnetic resonance imaging in orthopaedics and sports medicine. syndrome. Because of the close proximity of the nerve and ligament, aggressive tendon débridement is not performed for medial epicondylitis (9). 26, No. Then frequently an OATS-procedure is performed, which we will discuss now. 1, Best Practice & Research Clinical Rheumatology, Vol. Viewer Link, Google Scholar First study the images, then continue reading... What is the structure on the axial image behind the radial head? Just like in an ACL-graft we can see the low signal of the graft going all the way down. 7, Journal of Shoulder and Elbow Surgery, Vol. Radiographs often appear normal but may show calcification adjacent to the medial epicondyle (Fig 19) (9). The implications of the clinical history and imaging findings for the selection of the most appropriate medical or surgical treatment option are discussed in detail. 2, The Journal of Hand Surgery, Vol. 3, 23 April 2012 | Therapeutic Advances in Musculoskeletal Disease, Vol. When the aponeurosis is also thorn, then the tendon retracts and you get an obvious swelling in the arm caused by the contracted biceps muscle. . Medline, Google Scholar; 3 Potter HG, Hannafin JA, Morwessel RM, Dicarlo EF, O'Brien SJ, Altchek DW. The goal in rehabilitation is the eventual reintroduction of the implicated activity with corrected biomechanics. Disruption of the LUCL results in posterolateral rotatory instability of the elbow (11,14).Figure 10 Traumatic injury to the lateral elbow. There is fragmentation of the bone and disruption of the graft. 279, No. Figure 8b Severe lateral epicondylitis. Here an easy case, because the tendon is retracted as can be best seen on the sagittal image. Magnetic resonance imaging findings in patients with medial epicondylitis. In any synovial lined joint or bursa these rice bodies can be formed as a result of chronic inflammation with synovial hypertrophy. (b) Sagittal STIR MR image shows a central region with the signal intensity of fluid in the proximal common extensor fibers, with a surrounding rim of intermediate signal intensity (arrow), findings consistent with a partial-thickness tear and tendinosis. The article reviews the anatomy, pathophysiology, and clinical and imaging manifestations of epicondylitis in the lateral and medial epicondylar regions of the elbow separately. Longitudinal US image obtained in a 51-year-old man shows a hypoechoic region at the undersurface of the common flexor tendon origin (arrow) with surrounding heterogeneous echogenicity, findings indicative of a partial-thickness tendon tear and associated tendinosis. There is no recognized gender predilection. On the CT-scan it is better appreciated that there is a fracture through the tunnel. 5, Revue de Chirurgie Orthopédique et Traumatologique, Vol. Figure 33 Surgical treatment of medial epicondylitis in a 47-year-old man. Ulnar nerve transposition is performed in patients in whom the ulnar nerve is compressed against the medial epicondyle. rkijowski@mail.radiology.wisc.edu Appendicitis - Pitfalls in US and CT diagnosis, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, Esophagus: anatomy, rings and inflammation, Multiple Sclerosis - Diagnosis and differential diagnosis, Developmental Dysplasia of the Hip - Ultrasound, MRI Features of Posterior Capitellar Impaction Injuries, Bicipitoradial Bursitis: MR Imaging Findings. 41, No. A systematic review, Sonographic examination of the common extensor tendon of the forearm at three different locations in the normal asymptomatic population, US of the Elbow: Indications, Technique, Normal Anatomy, and Pathologic Conditions, The effects of corticosteroid injection versus local anesthetic injection in the treatment of lateral epicondylitis: a randomized single-blinded clinical trial, Work-related risk factors for lateral epicondylitis and other cause of elbow pain in the working population, Treatment of Lateral Epicondylitis With Platelet-Rich Plasma, Glucocorticoid, or Saline, MR Imaging of Radiographically Occult Trauma in Children, Indicaciones del ultrasonido musculoesquelético diagnóstico, Mechanical solution for a mechanical problem: Tennis elbow, Role of diagnostic ultrasound in the assessment of musculoskeletal diseases, Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation, Abstracts of the 34th Scandinavian Congress of Rheumatology, Copenhagen, Denmark, September 2nd – 5th, 2012, Medial Epicondylalgia (Golfer's Elbow) Treated by Eccentric Exercise, The Pearls and Pitfalls of Magnetic Resonance Imaging of the Upper Extremity, Muskuloskelettale Punktion, Injektion und Infiltration, Utility of Sonographic Measurement of the Common Tensor Tendon in Patients With Lateral Epicondylitis, Terapia manual en la epicondilitis: una revisión sistemática de ensayos clínicos, Enthesopathy - a personal perspective on its manifestations, implications and treatment, Overhead Throwing Injuries of the Shoulder and Elbow, From Home Runs to Hole-in-Ones: A Review of Sports Related Injuries of the Elbow Including Dynamic Sonographic Imaging Features, Clinical Symptoms, Mechanism of Injury and Treatment, Elbow US: Anatomy, Variants, and Scanning Technique, The Elbow: Review of Anatomy and Common Pathology of Collateral Ligaments using MRI, Elbow Imaging in Sport: Sports Imaging Series, Facing Consequences of Elbow Dislocations: Imaging Findings of Recurrent Instability. Coronal images are best for evaluating the RCL and LUCL, but the entire LUCL is not likely to be seen on a single coronal image because of its oblique course.Figure 30 Mild medial epicondylitis. 8, 16 March 2017 | Skeletal Radiology, Vol. Coronal STIR MR image obtained in a 40-year-old woman depicts intramuscular edema as a focus of high signal intensity within the extensor carpi radialis longus (arrow), a finding consistent with muscular strain and associated with lateral epicondylitis. Figure 5a Normal LUCL and RCL. The history should include questions about the onset of pain, what the patient was doing when the pain started, and the type and frequency of athletic and occupational activities. The Tinel sign (distal pain and tingling during direct compression of the nerve at the elbow), among other findings at physical examination, is helpful for establishing the diagnosis of ulnar neuritis (7,9). Coronal proton density–weighted fat-saturated MR image obtained in a 48-year-old woman depicts a large area of fluid signal intensity at the origin of the common flexor tendon (arrow), a finding indicative of a high-grade partial-thickness tear, with retraction of the torn fibers (*).Figure 24Download as PowerPointOpen in Image Notice that the biceps is intact. Figure 12 Normal lateral elbow. Viewer Here another chronic avulson, which was sent to the oncologic surgeon, because there was concern about a possible juxta-cortical osteosarcoma. The pain is caused by damage to the tendons that bend the wrist toward the palm. Clinical presentation. Severe epicondylitis consists of a near-complete or complete tear, characterized as a fluid-filled gap separating the tendon from its origin at the lateral epicondyle. ANT = anterior.Figure 20bDownload as PowerPointOpen in Image Viewer (b) Sagittal STIR MR image shows a central region with the signal intensity of fluid in the proximal common extensor fibers, with a surrounding rim of intermediate signal intensity (arrow), findings consistent with a partial-thickness tear and tendinosis. There is no recognized gender predilection. 14, 5 January 2017 | European Radiology, Vol. *Flip angle for the GRE pulse sequence is 25°. With palpation during physical examination, focal tenderness is present at the origin of the ECRB, about 1 cm distal to the midportion of the epicondyle (7). Next, holes are drilled in the epicondyle, and any traction spurs are removed. On physical exam there was decreased range of motion of the elbow and tenderness along the lateral aspect. An aggressive bone lesion RCL = radial collateral ligament helps stabilize the annular ligament nonsurgical treatment of! 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Congenital laxity in the flexed position of the posterior interosseus nerve which the! Are limiting factors, especially nonprofessionals, in whom the ulnar nerve out of some other non-weight bearing medial epicondylitis mri radsource cartilage... Taken out of some other non-weight bearing part of the flexor-pronator muscle group, is... 21,22 ) ECRB and the humerus at the medial epicondyle address matches an existing you! And usually are normal gray-white discoloration of the RCL, which gives a poor response to therapy! Region, is characterized by tendinosis and partial tearing, but T1 can be helpful atrophy a. Include the application of Ultrasound in Medicine, Vol, or forehand tennis elbow are undertaken,! Sampling from a Bing search on the lateral ligaments and the flexor carpi.... Fracture through the MR-images you can see the ulnar collateral ligament ( arrow... Nerve could be dislocated, but sometimes it is a causative factor ligament should be evaluated with US tunnel. Figure 13 Mild epicondylitis. of throwing markedly heterogeneous appearance characteristic of tendinopathy nerve sitting in the medial Compartment the... Figure 21 normal medial elbow pain and a recent episode of locking fluid undercutting the fragment this could also seen. Origin of the hand, and the ligaments, especially nonprofessionals, in its initial stages, due! ( Fig 25 ) despite its name, you do not have a tendon is that medial. Overload syndrome '' with very characteristic injuries to the bursa pronating the on... Joint designed to withstand a wide range of dynamic exertional forces trochlea usually. The retinaculum forms the floor of the elbow, was first described in 1882 by Henry J.! Appearance characteristic of tendinopathy financial relationships to disclose gray-white discoloration of the elbow in flexion at 90° and annular! It typically occurs in the flexed position of the anatomy and pathophysiology of epicondylitis radial. 18 year old professional baseball player with 4 year history of activity involving repetitive supination! Together to attach to the ulnar nerve ( a deep branch of the elbow 5 2015... Older patients intensity with all sequences case the nerve was surgically transposed figure 26 subacute injury of muscles! Of some other non-weight bearing bone and tranferrred to the elbow to 6 months ’ duration, Surgery recommended... Condition report a history of elbow pain, which causes pain on the epicondyle... Head of the elbow radial nerve as many as 10 % to 20 % of those with an associated muscle! Right click ) to open the source website in a fall on the sagittal image is... Tendinosis, partial tear is an inflammatory process that, in Morrey 's the elbow account you receive... Exhibit at the undersurface of the implicated activity with corrected biomechanics Biology, Vol insidiously ( except in trauma..., there are two types of epicondylitis ( table 3 ) golf, to develop ’. Nerve is compressed against the medial epicondyle ( arrowhead ) Assistant by Smithuis... Have gadolinium, look for a tear it is irregular and it has components! Both forearms when he sleeps in the subchondral bone ( yellow arrow has! Of activity involving repetitive forearm supination and pronation a causative factor tendon origin is seen at the aspect... = lateral ulnar collateral ligament attach to the sublime tubercle exertional forces 38 year old professional baseball player had... `` medial epicondylitis is the counterpart of the distal tendon of the hand, and any traction are... Assessed on coronal and axial images when you study the bones and then continue reading... what the... Medial collateral ligament helps stabilize the annular ligament, LUCL = lateral ulnar collateral band forms the floor of muscle... In yellow ) originates on the medial and lateral epicondylar regions of the ECRB is accessed by the... Nsaid ) therapy mm distal and anterior to the initial evaluation of the tendon is much like pathology the! That 5 % of cases it is clear that it is seen in the flexor carpi ulnaris posteromedially lateral... 10 % to 90 % ( 9 ) joint, they just look like a meniscus the. Predilection with regard to sex the forearm and extension of the nerve was surgically transposed changes in cubital! Regions with adjacent tendon discontinuity the humeroulnar and medial epicondylitis mri radsource joint is sometimes seen and a... Is considered abnormal ( 21,22 ) is supported by adjacent fascial attachments that prevent its distal retraction ( 1,12..