doi:10.1136/bjsm.24.3.151 1990;24;151-155 Br. J. Sports Med.

  N Maffulli, R Regine, F Carrillo, G Capasso and S Minelli  

players.Tennis elbow: an ultrasonographic study in tennis

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Br. J. Sp. Med; Vol 24, No. 3

Tennis elbow: an ultrasonographic study in tennisplayers

N. Maffulli, MD1, R. Regine, MD2, F. Carrillo, MD3, G. Capasso, MD4 and S. Minelli, MD51,4 University of Naples, First Medical School, First Institute of Orthopaedics and Traumatology, Naples, Italy2,3,5 University of Naples, Second Medical School, First Institute of Radiology, Naples, Italy1 University of London, Institute of Child Health, Respiratory and Anaesthetic Unit, Sports Medicine Laboratoryand University of Naples, First Medical School, Institute of Physiology, Section of Sports Physiopathology

The findings of ultrasound examination at and around thelateral humeral epicondyle in 41 tennis players sufferingfrom so called tennis elbow are reported. Ultrasoundexaminations were performed with a real time ultrasoundmachine. The tenderness and functional impairment oftennis elbow may be caused by several different lesions, attimes appearing in association. Six ultrasonographiccharacteristics could be identified:

Enthesiopathy The proximal part of the tendon wasenlarged and there were echogenicity alterations.Tendonitis The tendon of the extensor carpi radialisbrevis was enlarged and areas of dyshomogeneoushypoechogenicity were evident with loss of thenormal microscopic waveform structure of the tendoncollagen.Peritendonitis A thickening of the peritendonouslining was present.Bursitis A bursa was located on the inferior surfaceof the tendon of the extensor carpi radialis brevis.Intramuscular haematoma Some circular or ovoidhypoechogenic areas within the muscular substanceof the extensor carpi radialis brevis were evident.Mixed lesions These were not correlated with theintensity and the duration of the symptoms.

Ultrasonographic examination gives a detailed iamge ofthe structures involved in the tennis elbow syndrome,confirms the diagnosis, and may be useful in monitoringtreatment.

Keywords: Tennis elbow, sports injuries, ultrasonography

IntroductionThe term 'tennis elbow' (TE) refers to a painfulcondition at or around the lateral epicondyle of thehumerus and the common extensor origin. It mayradiate along the forearm. There is also localizedtenderness over these areas, and pain on resistedactive extension of the wrist when the elbow is fullyextended'.Although chronic overuse is said to cause lateral

epicondylitis, its aetiology is still not well defined2,and several factors have been proposed. Some

authors have suggested that enthesiopathy may bethe unifying cause3, although several other lesionshave been reported4. Some neurological syndromes,namely cervical spine disease with radiculojathy5and posterior interosseus nerve entrapment, maymimic the tennis elbow syndrome. Bursae have alsobeen associated with TE7.The factors involved In the aetiology of tennis

elbow have been widely discussed8. On a purelyanatomical basis, they include detachment from thelateral epicondyle of muscular or tendinous fibres ofthe extensor carpi radialis brevis during wristmovements, and impingement of bursae or synovialfolds between the fibres of the extensor carpi radialisbrevis and the elbow joint capsule9. A blood flowdisturbance, causing relative ischemia and degenera-tion of the soft tissues around the lateral epicondyle,has also been proposed as a possible causeRecent studies have shown that up to one third of

American local league tennis players may suffer fromtennis elbowl1. Only a minority recover fully withmedical treatment1. Causes indicate racquet factors,hitting technique, timing, and condition of the court.High frequency of play is the main contributoryfactor10' 11*We report the findings of ultrasound examination

in 41 tennis players suffering from TE.

Patients and methodsThe series presented consists of 41 tennis players(24.3 ± 7.3 years, range 16 to 36 years), only two werefemale. All were experienced, training three to fivetimes a week and competing at least at regional levelin their respective age groups for the year before thestudy. They had all presented with pain on the lateralaspect of the lateral humeral epicondyle and/or thecommon extensor origin for an average of 2.2 months(range 17 days to 9.8 months) before the study. Aboutone third (15) had already sought medical advice withno beneficial effect. Neurological involvement andrheumatic diseases had been excluded in all patients,and a definite diagnosis of TE was confirmedindependently by both the orthopaedic surgeonsinvolved in the study.

All ultrasound examinations were performed usinga real time ultrasound machine, equipped with a

Br. J. Sports Med., Vol 24, No. 3 151

Address for correspondence: N. Maffulli, Institute of Child Health,Sports Medicine Laboratory, 30 Guildford Street, London WC1N1EH, UK© 1990 Butterworth-Heinemann Ltd0306-4179/90/030151-05

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Tennis elbow - an ultrasongoraphic study: N. Maffulli et al.

linear 7MHz probe, and a sector 5MHz probe.Ultrasound scan was performed by one of theradiologists, ensuring that the scanning beam wasperpendicular to the structures studied1 . The analy-sis of the scan was made on images by two otherradiologists who had no prior knowledge of thepatient whose image they were examining.

Eight patients were followed up to completeclinical resolution.

ResultsAnalysis of the ultrasound scan images confirmed themultiplicity of lesions associated with this clinicalsyndrome.

Enthesiopathy (five cases) The proximal part ofthe extensor carpi radialis brevis (ECRB) tendonwas enlarged and there were echogenicityalterations.Tendonitis (15 cases) The main tendon of ECRPwas enlarged and areas of dishomogeneous

hypoechogenicity were evident together withloss of the normal waveform structure of thetendon (Figure 1).Peritenonitis (four cases) A thickening of theperitendonous lining was present. In one case,this was accompanied by an enlargement of thetendon itself but it was still possible to identify itsnormal structure.Bursitis (five cases) An ovoid, well defined,hypoechoich area, a bursa, was located on theinferior surface of the tendon of the extensorcarpi radialis brevis. It displaces the tendondorsally (Figure 2).Intramuscular haematoma (two cases) Some circu-lar or ovoid hypoechogenic areas within themuscular substance of the ECRB, of differentechogenicity from the muscle and ill-definedborders, were evident about one centimetre fromthe extensor carpi radialis attachment (Figure 3).Mixed lesions (seven cases) They were notcorrelated with the intensity and the duration ofthe symptoms.

Figure 1. Tendonitis The tendon of the extensor carpi radialis brevis is enlarged and some areas of ultrasonic dyshomogeneity

~~~~~~~~~~~~~~~~~~~~~~~~. ..... ... .. .. ... ......_

are presen.The.normal wavfor...strc.te i l l.

dipae drally

_~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...

EX~~~~ CR~~~~

Figure 3. Intramuscular haematoma An ovoid area of hypoechogenic appearance, located within the muscular substance ofthe extensor carpi radialis brevis, about one centimetre from its attachment, is shown

152 Br. J. Sports Med., Vol 24, No. 3

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Tennis elbow - an ultrasonographic study: N. Maffulli et al.

EME -.2 ~~~~~~~~~CR

HU

Figur4. Eolutin of n itauclrheaoatetdcnevtvl o:ALreoodhpehi asivdn

jut isaltoth msclotediou jncio. idle Te as i edueXnsz fe w ots otm ormnhaferte irtscnter s tilsoe lraoncevdnc o heorgna nta-ucuarhemtoa btth pten wsful

asymptomatic W

Br. J. Sports Med., Vol 24, No. 3 153

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Tennis elbow - an ultrasonographic study: N. Maffulli et al.

No ultrasonographic abnormalities (threecases) This may have been due either to theacuteness of the lesions or their mildness ortechnical factors causing them to be beyond theresolution of the scanner used.

In 14 cases the tendon of ECRB appeared as adistinct anatomical structure9. (Two patients with anultrasonographic picture of enthesiopathy, six withtendonitis, two with peritendonitis, one with bursi-tis, two with mixed lesions and one with nodetectable ultrasonographic alterations.)

Discussion

The common extensor origin is classically describedas a tendinous mass13. However, in accordance withother studies9, we found that the tendon of theextensor carpi radialis brevis could be a distinctstructure. The fact that the surface of attachment isthus reduced may account for the decreased ability tosustain repeated stresses, and may thus be apredisposing factor for overuse injuries.The pain evoked by movements and the localized

tenderness can be explained by all the findings of thisstudy. Typically, the symptoms are reproduced whenthe elbow is fully extended with the wrist dorsiflexed,and a downward force is applied on the middle fingerwith the patient resisting it'4, and in the last 200 ofextension when the forearm is pronated and the wristis extended from a fully flexed position8. In theseforced movements, the muscle either compresses theunderlying inflamed bursa, or, being incapable offurther lengthening, muscle or tendon micro-tearsare produced.At present, it is difficult to know whether

ultrasonographic findings can be used as a prognosticmeans. In cases of definite bursitis, local steroidinfiltration was prescribed, while muscle tears weretreated conservatively with rest, stretching, oralNSAIDs and ultrasound therapy.Three cases of long-standing and recurrent TE with

an ultrasound diagnosis of tendonitis were treatedsurgically with multiple incisions along the longitu-dinal axis of the tendon. One further case, ultraso-nographically diagnosed as an enthesiopathy, wastreated with percutaneous release of the epicondylarmuscle origin'5 with full recovery. All the patientsoperated on are currently playing and regardthemselves as fully healed.Up to now, it is unclear how ultrasonographic

findings may influence the management of TE, but atentative classification of the underlying anatomicalbasis of the condition may be attempted.

Key to illustrationsB, bursa; CA, caudal; CR, cranial; E, lateral humeralepicondyle; EX, extensor carpi radialis brevis; H, haematoma;HU, humerus; M, other musdles; T. tendon of the extensorcarpi radialis brevis, or common extensor muscles tendinousmass

Extra-tendinous alterationsMuscular tears Haematoma of circular or ovoidappearance, hypoechogenic.Bursitis Cavity lying just below the extensorcarpi radialis brevis, adjacent to its radial head.

Pathology of the tendon"6Enthesiopathy Enlargement of the proximal partof the tendon and echogenicity alterations.Tendonitis Enlargement and alterations of thesubstance of the tendon, possibly with inflam-matory and degenerative appearances.Peritendonitis Thickening of the tendon sheathall the way to the area of the muscle-tendonjunction. A stenosing tenosynovitis may result17.Mixed lesions Any combination of the abovementioned pathologies may, at least theoretical-ly, occur.

Until recently, although it was recognised that thevariable sites of local tenderness could imply differentpathology1, tennis elbow was considered a singleentity2. To our knowledge, this is the first in vivostudy to show non-surgically that TE may be causedby several different pathological lesions.

Ultrasonographic examination gives a detailedimage of the structures involved in the tennis elbowsyndrome, confirms the diagnosis, and may be usefulin monitoring treatment (Figure 4). Due to its safety,its contained costs, and the easiness of the scan itself,we believe that ultrasonography can become routinepractice in the assessment of TE.However, a potential limitation of the technique is

the availability of high quality transducers, given thatthe axial resolving power of a 7.5MHz transducer isaround five mm. In our hands, this has allowed us todetect intramuscular haematomas of about two mmin diameter, and to study tendinous lesions indetail18, being able to follow the evolution ofpost-traumatic haematoma in ruptured tendons'9,and the image of single-thread suture in repairedtendons20.

References1 Chard, M.D. and Hazleman, B.L. Tennis elbow - a

reappraisal Br J Rheumatol 1989, 28, 186-1902 Binder, A., Parr, G., Page Thomas, P. and Hazleman,

B. A clinical and thermographic study of lateralepicondylitis Brit I Rheum 1983, 22, 77-81

3 Niepal, G.A. and Sitaj, S. Enthesopathy Clin RheumDis 1979, 5, 857-872

4 Friedlander, H.L., Reid, R.L. and Cape, R.I. Tenniselbow Clin Orthop 1967, 51, 109-116

5 Murray-Leslie, C.F. and Wright, V. Carpal tunnelsyndrome, humeral epicondylitis and the cervicalspine. A study of clinical and dimensional relations BrMed J 1976, 1, 1439-1442

6 Werner, C. Lateral elbow pain and posterior interos-seus nerve entrapment Acta Orthop Scand 1979, Suppl,174, 16-2

7 Bosworth, D.M. The role of the orbicular ligament intennis elbow J Bone Joint Surg 1955, 37A, 527-533

8 Nirschl, R.P. Tennis elbow Orthop Clin North Am 1972,4, 787-800

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9 Briggs, C.A. and Elliot, B.G. Lateral epicondylitis. Areview of the structures associated with tennis elbowAnat Clin 1985, 7, 149-153

10 Legwold, G. Tennis elbow: joint resolution byconservative treatment and improved technique PhysSportsmed 1984, 12, 168-182

11 Carrol, R. Tennis elbow: incidence in local leagueplayers Br I Sports Med 1981, 15, 250-256

12 Fornage, B.D. The hypoechoic normal tendon. Apitfall I Ultrasound Med 1987, 6, 19-22

13 Last, R.J. 'Anatomy. Regional and Applied' ChurchillLivingstone, Edinburgh, 1984

14 Kulund, D.N. 'The Injured Athelete' J.B. LippincottCompany, Philadelphia, 1982

15 Baumgard, S.H. and Schwartz, D.R. Percutaneousrelease of the epicondylar muscles for humeralepicondylitis Am I Sports Med 1982, 10, 233-236

16 Puddu, G., Ippolito, E. and Postacchini, F. Aclassification of Achilles tendon disease Am J SportsMed 1976, 4, 145-149

17 Viikari-Juntura, E. Tenosynovitis, peritendinitis andthe tennis elbow syndrome Scan I Work Environ Health1984, 10, 443-449

18 Maffulli, N., Regine, R., Angelillo, M., Capasso, G.and Filice, S. Ultrasound diagnosis of Achilles tendonpathology in runners Br J Sports Med 1987, 21, 158-162

19 Maffulli, N., Dymond, N.P. and Capasso, G. Ultraso-nographic findings in subcutaneous rupture of Achil-les tendon J Sports Med Phys Fit 989, 29, 365-368

20 Maffulli, N., Dymond, N.P. and Regine, R. Surgicalrepair of ruptured Achilles tendon in sportsmen andsedentary patients: a longitudinal ultrasound assess-ment Int I Sports Med 1990, 11, 78-84

Royal College of Surgeons of EnglandPorritt Fellowship

Applications are invited for the 1991 aware of the Porritt Fellowship given by the Winthrop Foundation inhonour of the Rt Hon The Lord Porritt GCMG CGVO CBE FRCS, to encourage the study of sports medicineand injuries in sport.The purpose of the Porritt Fellowship is to encourage study of the physiology and biochemistry of sportingachievement and/or the aetiology, pathology, prevention and treatment of accidents and injuries associatedwith sporting activities. The work may be carried out in the UK or abroad, and should be suitable forpublication or form part of a thesis for higher qualifications.A candidate must hold the Fellowship of a Royal College of Surgeons in Great Britain or Ireland, or of oneof their Faculties or be a medically qualified member of the staff of one of their scientific departments.Successful candidates will probably hold university, NHS or other salaried posts, and will use theirFellowships to travel to centres at home or abroad to study.The value of the Fellowship is £5,000 tenable normally for a period of one year, from September 1991, and aPorritt Fellow may be invited to deliver a Porritt Lecture by the British Association of Sport and Medicine.

Applications must reach R.H.E. Duffett not later than Friday 26th April 1991 and must include thefollowing:

* Curriculum vitae* Statement (maximum 1000 words) of the study or research project, including the location and facilities

already available for the project* Particulars of the applicant's salary and of any additional financial support promised or applied for* Names and addresses of two referees, one ofwhom should be the head of the department in which the

applicant is working.Applications should be made to: RHE Duffett, MA, Secretary, The Royal College of Surgeons of England,35/43 Lincoln's Inn Fields, London WC2A 3PN, UK.

Br. J. Sports Med., Vol 24, No. 3 155

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