European Radiology

, Volume 27, Issue 8, pp 3460–3466 | Cite as

Extensor tendinopathy of the elbow assessed with sonoelastography: histologic correlation

  • Andrea S. Klauser
  • Mathias Pamminger
  • Ethan J. Halpern
  • Mohamed M. H. Abd EllahEmail author
  • Bernhard Moriggl
  • Mihra S. Taljanovic
  • Christian Deml
  • Judit Sztankay
  • Guenther Klima
  • Werner R. Jaschke



To compare agreement between conventional B-mode ultrasound (US) and compression sonoelastography (SEL) of the common extensor tendons of the elbow with histological evaluation.

Materials and methods

Twenty-six common extensor tendons were evaluated in 17 cadavers (11 females, median age 85 years and 6 males, median age 80 years). B-mode US was graded into: Grade 1, homogeneous fibrillar pattern; grade 2, hypoechoic areas and/or calcifications <30%; and grade 3 > 30%. SEL was graded into: Grade 1 indicated blue (hardest) to green (hard); grade 2 yellow (soft); and grade 3 red (softest). B-mode US, SEL, and a combined grading score incorporating both were compared to histological findings in 76 biopsies.


Histological alterations were detected in 55/76 biopsies. Both modalities showed similar results (sensitivity, specificity, and accuracy 84%, 81%, and 83% for B-mode US versus 85%, 86%, and 86% for SEL, respectively, P > 0.3). However, a combination of both resulted in significant improvement in sensitivity (96%, P < 0.02) without significant change in specificity (81%, P < 0.3), yielding an improved overall accuracy (92%).


Combined imaging of the extensor tendons with both modalities is superior to either modality alone for predicting the presence of pathologic findings on histology.

Key Points

Combination of B-mode US and SEL proved efficiency in diagnosing lateral epicondylitis.

Combination of B-mode US and SEL in lateral epicondylitis correlates to histology.

Combination of both modalities provides improved sensitivity without loss of specificity.


Sonoelastography Epicondylitis Ultrasound Tendinosis Histology 



Lateral epicondylitis







B-mode US

B-mode ultrasound


Region of interest



The scientific guarantor of this publication is Andrea S Klauser. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors has significant statistical expertise. Institutional Review Board approval was not indicated as this work was conducted on cadavers, who dedicated their bodies for research after death according to their will and they signed this consent form before death. Written informed consent was obtained from all subjects in this study. Methodology: Prospective, Diagnostic or prognostic study, Performed at one institution.


  1. 1.
    Connell D, Burke F, Coombes P et al (2001) Sonographic examination of lateral epicondylitis. AJR 176:777–82CrossRefPubMedGoogle Scholar
  2. 2.
    Miller TT, Shapiro MA, Schultz E, Kalish PE (2002) Comparison of sonography and MRI for diagnosing epicondylitis.JClin. Ultrasound 30:193–202Google Scholar
  3. 3.
    Levin D, Nazarian LN, Miller TT et al (2005) Lateral epicondylitis of the elbow: US findings. Radiology 237:230–4CrossRefPubMedGoogle Scholar
  4. 4.
    Jaen-Diaz JI, Cerezo-Lopez E, Lopez-de CF et al (2010) Sonographic findings for the common extensor tendon of the elbow in the general population. J Ultrasound Med 29:1717–24CrossRefPubMedGoogle Scholar
  5. 5.
    Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M (2006) Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 164:1065–74CrossRefPubMedGoogle Scholar
  6. 6.
    Walz DM, Newman JS, Konin GP, Ross G (2010) Epicondylitis: pathogenesis, imaging, and treatment. Radiographics 30:167–84CrossRefPubMedGoogle Scholar
  7. 7.
    Latham SK, Smith TO (2014) The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis. Orthop Traumatol Surg Res 100:281–6CrossRefPubMedGoogle Scholar
  8. 8.
    De Zordo T, Lill SR, Fink C et al (2009) Real-time sonoelastography of lateral epicondylitis: comparison of findings between patients and healthy volunteers. AJR 193:180–5CrossRefPubMedGoogle Scholar
  9. 9.
    Dones VC III, Grimmer K, Thoirs K, Suarez CG, Luker J (2014) The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review. BMC Med Imaging 14:10CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Havre RF, Elde E, Gilja OH et al (2008) Freehand real-time elastography: impact of scanning parameters on image quality and in vitro intra- and interobserver validations. Ultrasound Med Biol 34:1638–50CrossRefPubMedGoogle Scholar
  11. 11.
    Klauser AS, Miyamoto H, Bellmann-Weiler R, Feuchtner GM, Wick MC, Jaschke WR (2014) Sonoelastography: musculoskeletal applications. Radiology 272:622–33CrossRefPubMedGoogle Scholar
  12. 12.
    Klauser AS, Faschingbauer R, Jaschke WR (2010) Is sonoelastography of value in assessing tendons? Semin Musculoskelet Radiol 14:323–33CrossRefPubMedGoogle Scholar
  13. 13.
    Ahn KS, Kang CH, Hong SJ, Jeong WK (2014) Ultrasound elastography of lateral epicondylosis: clinical feasibility of quantitative elastographic measurements. AJR 202:1094–9CrossRefPubMedGoogle Scholar
  14. 14.
    Ooi CC, Malliaras P, Schneider ME, Connell DA (2014) “Soft, hard, or just right” applications and limitations of axial-strain sonoelastography and shear-wave elastography in the assessment of tendon injuries. Skelet Radiol 43:1–12CrossRefGoogle Scholar
  15. 15.
    Kocyigit F, Kuyucu E, Kocyigit A et al (2016) Association of real-time sonoelastography findings with clinical parameters in lateral epicondylitis. Rheumatol Int 36:91–100CrossRefPubMedGoogle Scholar
  16. 16.
    Klauser AS, Miyamoto H, Tamegger M et al (2013) Achilles tendon assessed with sonoelastography: histologic agreement. Radiology 267:837–42CrossRefPubMedGoogle Scholar
  17. 17.
    Miyamoto H, Halpern EJ, Kastlunger M et al (2014) Carpal tunnel syndrome: diagnosis by means of median nerve elasticity--improved diagnostic accuracy of US with sonoelastography. Radiology 270:481–6CrossRefPubMedGoogle Scholar
  18. 18.
    Giyoung P, Dongrak K, Junghyun P (2014) Diagnostic confidence of sonoelastography as adjunct to greyscale ultrasonography in lateral elbow tendinopathy. Chin Med J 127:3110–5Google Scholar
  19. 19.
    Khoury V, Cardinal É (2009) “Tenomalacia”: a new sonographic sign of tendinopathy? Eur Radiol 19:144–6CrossRefPubMedGoogle Scholar
  20. 20.
    Rosskopf AB, Ehrmann C, Buck FM, Gerber C, Fluck M, Pfirrmann CW (2016) Quantitative shear-wave US elastography of the supraspinatus muscle: reliability of the method and relation to tendon integrity and muscle quality. Radiology 278:465–74CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2017

Authors and Affiliations

  • Andrea S. Klauser
    • 1
  • Mathias Pamminger
    • 1
  • Ethan J. Halpern
    • 2
  • Mohamed M. H. Abd Ellah
    • 1
    • 3
    Email author
  • Bernhard Moriggl
    • 4
  • Mihra S. Taljanovic
    • 5
  • Christian Deml
    • 6
  • Judit Sztankay
    • 7
  • Guenther Klima
    • 8
  • Werner R. Jaschke
    • 1
  1. 1.Department of RadiologyMedical University of InnsbruckInnsbruckAustria
  2. 2.Department of Radiology and Urology, Jefferson Prostate Diagnostic and Kimmel Cancer CenterThomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Department of Diagnostic Radiology, South Egypt Cancer InstituteAssiut UniversityAssiutEgypt
  4. 4.Department of AnatomyMedical University of InnsbruckInnsbruckAustria
  5. 5.Department of Medical ImagingBanner- University Medical CenterTucsonUSA
  6. 6.Department of Trauma SurgeryMedical University of InnsbruckInnsbruckAustria
  7. 7.Department of RadiotherapyMedical University of InnsbruckInnsbruckAustria
  8. 8.Department of Histology & EmbryologyMedical University of InnsbruckInnsbruckAustria

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