Ultrasound Measurements of the ECRB Tendon Shows Remarkable Variations in Patients with Lateral Epicondylitis

Document Type : RESEARCH PAPER


1 Department of Orthopaedic Surgery, Upper limb unit, Amphia Hospital, Breda, the Netherlands

2 Foundation for Orthopaedic Research, Care and Education, Amphia Hospital, Breda, the Netherlands

3 Department of Radiology, Amphia Hospital, Breda, the Netherlands

4 Department of Orthopaedic Surgery, Upper limb unit, Amphia Hospital, Breda, the Netherlands--- Coronel Institute of Occupational health, Amsterdam University Medical Centers, the Netherlands

5 Department of Orthopaedic Surgery, Amsterdam University Medical Centers, the Netherlands


Background: Lateral epicondylitis (LE) most commonly affects the Extensor Carpi Radialis Brevis (ECRB) tendon and
patients are generally treated with injection therapy. For optimal positioning of the injection, as well as an estimation of
the surface area and content of the ECRB tendon to determine the volume of the injectable needed, it is important to
know the exact location of the ECRB in relation to the skin as well as the variation in tendon length and location. The
aim of this study was to determine the variation in location and size of the ECRB tendon in patients with LE.
Methods: An observational sonographic evaluation of the ECRB tendon was performed in 40 patients with LE. The
length of the ECRB tendon, distance from the cutis to the center of the ECRB tendon, the length of the osteotendinous
junction at the epicondyle and the distance from cutis to middle of the osteotendinous junction were measured.
Results: The average tendon length was 1.68cm (range 1.27-1.98; SD 0.177). Compared to women, the ECRB tendon
of men was on average 0.12cm longer. Overall, the average distance from cutis to the center of the ECRB was 0.75cm
(range 0.50-1.46cm; SD 0.210), the average length of the junction was 0.55cm (range 0.35-0.87; SD 0.130), and the
distance from cutis to middle of the osteotendinous junction was 0.73cm (range 0.40-1.25cm; SD 0.210).
Conclusion: The size and depth of the ECRB tendon in patients with LE is largely variable. While there are no studies
yet suggesting sono-guided injection to be superior to that of blind injection, the anatomic variability of this study
suggests that the accuracy of injection therapy for LE might be compromised when based solely on bony landmarks
and therefore not fully reliable. As a result, there is value in further studies exploring the accuracy of the ultrasound
guided injection techniques.
Level of evidence: IV


Main Subjects

1. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper
C. Occupation and epicondylitis: a population-based
study. Rheumatology (Oxford). 2012; 51(2):305-10.
2. Van der Linden MW, Westert GP, Bakker DD,
Schellevis F. Tweede Nationale Studie naar ziekten
en verrichtingen in de huisartspraktijk: Klachten en 
aandoeningen in de bevolking en in de huisartspraktijk.
Utrecht: NIVEL; 2004.
3. Lisdonk EH van de, Bosch WJHM van den, Lagro-
Janssen ALM, Schers HJ. Ziekten in de huisartspraktijk.
Houten: Bohn Stafleu van Loghum; 2016.
4. Hamilton PG. The prevalence of humeral epicondylitis:
a survey in general practice. J R Coll Gen Pract. 1986;
36(291): 464–5.
5. Noh KH, Moon YL, Jacir AM, Kim KH, Gorthi V.
Sonographic probe induced tenderness for lateral
epicondylitis: an accurate technique to confirm the
location of the lesion. Knee Surg Sports Traumatol
Arthrosc. 2010; 18(6):836-9.
6. Verhaar JA. Tennis elbow. Anatomical, epidemiological
and therapeutic aspects. Int Orthop. 1994; 18(5):263-7.
7. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis:
pathogenesis, imaging, and treatment. Radiographics.
2010; 30(1):167-84.
8. Coombes BK, Bisset L, Vicenzino B. A new integrative
model of lateral epicondylalgia. Br J Sports Med. 2009;
9. Kraushaar BS, Nirschl RP. Tendinosis of the elbow
(tennis elbow). Clinical features and findings of
histological, immunohistochemical, and electron
microscopy studies. J Bone Joint Surg Am. 1999;
10. Haahr JP, Andersen JH. Physical and psychosocial
risk factors for lateral epicondylitis: a population
based case-referent study. Occup Environ Med. 2003;
11. Bot S, van der Waal JM, Terwee CB, van der Windt DA,
Bouter LM, Dekker J. Course and prognosis of elbow
complaints: a cohort study in general practice. Ann
Rheum Dis. 2005; 64(9): 1331-6.
12. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri
LM. Psychological aspects of persistent pain: current
state of the science. J Pain. 2004; 5(4):195-211.
13. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen
K, Buchbinder R, Fredberg U, et al. Comparative
effectiveness of injection therapies in lateral
epicondylitis: a systematic review and network metaanalysis
of randomized controlled trials. Am J Sports
Med. 2013; 41(6):1435-46.
14. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam
F, Panahi A. Autologous blood versus corticosteroid
local injection in the short-term treatment of lateral
elbow tendinopathy: A randomized clinical trial of
efficacy. Am J Phys Med Rehabil. 2010; 89(8):660-7.
15. Ozturan KE, Yucel I, Cakici H, Guven M, Sungur I.
Autologous blood and corticosteroid injection and
extracoporeal shock wave therapy in the treatment of
lateral epicondylitis. Orthopedics. 2010; 33(2):84-91.
16. Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE.
Comparison of autologous blood, corticosteroid, and
saline injection in the treatment of lateral epicondylitis:
A prospective, randomized, controlled multicenter
study. J Hand Surg Am. 2011; 36(8):1269-72.
17. Dojode CM. A randomised control trial to evaluate
the efficacy of autologous blood injection versus
local corticosteroid injection for treatment of lateral
epicondylitis. Bone Joint Res. 2012; 1(8):192-7.
18. Jindal N, Gaury Y, Banshiwal RC, Lamoria R, Bachhal
V. Comparison of short term results of single injection
of autologous blood and steroid injection in tennis 
elbow: A prospective study. J Orthop Surg Res. 2013;
19. Arik HO, Kose O, Guler F, Deniz G, Egerci OF, Ucar M.
Injection of autologous blood versus corticosteroid
for lateral epicondylitis: A randomized controlled
study. J Orthop Surg (Hong Kong). 2014; 22(3):333-7.
20. Keijsers R, van den Bekerom MPJ, Koenraadt KLM,
Bleys RLAW, van Dijk CN, Eygendaal D, et al. Injection
of tennis elbow: Hit and miss? A cadaveric study of
injection accuracy. Knee Surg Sports Traumatol
Arthrosc. 2017; 25(7):2289-92.
21. Kalainov DM, Cohen MS. Posterolateral rotatory
instability of the elbow in association with lateral
epicondylitis. A report of three cases. J Bone Joint Surg
Am. 2005; 87(5):1120-5.
22. Kwak SH, Lee SJ, Jeong HS, Do MU, Suh KT. Subtle
elbow instability associated with lateral epicondylitis.
BMC Musculoskelet Disord. 2018; 19(1):136.
23. Arrigoni P, Fossati C, Zottarelli L, Brady PC, Cabitza
P, Randelli P. 70° frontal visualization of lateral
compartment of the elbow allows extensor carpi
radialis brevis tendon release with preservation of
the radial lateral collateral ligament. Arthroscopy.
2014; 30(1):29-35.
24. Altay T, Günal I, Oztürk H. Local injection treatment
for lateral epicondylitis. Clin Orthop Relat Res. 2002;
25. Zeisig E, Ohberg L, Alfredson H. Extensor origin
vascularity related to pain in patients with Tennis
elbow. Knee Surg Sports Traumatol Arthrosc. 2006;
26. Pienimäki T, Siira P, Vanharanta H. Widespread pain in
chronic epicondylitis. Eur J Pain. 2011; 15(9):921-7.
27. du Toit C, Stieler M, Saunders R, Bisset L, Vicenzino B.
Diagnostic accuracy of power Doppler ultrasound in
patients with chronic tennis elbow. Br J Sports Med.
2008; 42(11):872-6.
28. Levin D, Nazarian LN, Miller TT, O’Kane PL, Feld RI,
Parker L, et al. Lateral epicondylitis of the elbow: US
findings. Radiology. 2005; 237(1):230-4.
29. Miller TT, Shapiro MA, Schultz E, Kalish PE. Comparison
of sonography and MRI for diagnosing epicondylitis. J
Clin Ultrasound. 2002; 30(4):193-202.
30. Connell D, Burke F, Coombes P, McNealy S, Freeman
D, Pryde D, et al. Sonographic examination of
lateral epicondylitis. AJR Am J Roentgenol. 2001;
31. Lee MH, Cha JG, Jin W, Kim BS, Park JS, Lee HK, et al.
Utility of sonographic measurement of the common
tensor tendon in patient with lateral epicondylitis.
AJR Am J Roentgenol. 2011; 196(6):1363-7.
32. Krogh TP, Fredberg U, Christensen R, Stengaard-
Pedersen K, Ellingsen T. Ultrasonographic assessment
of tendon thickness, doppler activity and bony spurs
of the elbow in patients with lateral epicondylitis and
healthy subjects; A Reliability and Agreement Study.
Ultraschall Med. 2013; 34(5):468-74.