Tennis and Golfer's Elbow in Ajax: The Role of Ultrasound

Here is a myth worth clearing up first: you do not need to play tennis to develop tennis elbow, and you do not need to own a set of golf clubs to develop golfer’s elbow. Most people diagnosed with either condition have never been near a court or a course. They are carpenters and hairdressers, office workers who spend long days on a mouse, parents lifting car seats, home cooks chopping vegetables and gardeners pulling weeds through a long summer weekend.

The names stuck because the conditions were first described in players of those sports, but what they really describe is pain where the forearm muscles attach to the bony bumps on either side of the elbow. This article explains those two areas, how health-care providers usually approach elbow pain, and where an ultrasound fits in when one is requested. It is written for patients in Ajax and the nearby communities of Pickering and Whitby, and it is general information rather than medical advice.

Two bumps, two groups of muscles

Feel the outside of your elbow with the arm bent and you will find a small bony knob. There is a matching one on the inside. These are the lateral and medial epicondyles of the upper arm bone, and each one is an anchor point for a group of forearm muscles.

The outside: tennis elbow

The muscles that attach on the outer side extend the wrist and fingers, meaning they lift the back of the hand upward. They also help steady the wrist whenever you grip something firmly. Their shared tendon is called the common extensor tendon. When this area becomes painful, the condition is known medically as lateral epicondylitis or lateral elbow tendinopathy, and informally as tennis elbow.

The inside: golfer’s elbow

The muscles on the inner side flex the wrist and fingers, curling the hand downward and helping you grip. Their shared tendon is the common flexor tendon. Pain here is called medial epicondylitis or medial elbow tendinopathy, or golfer’s elbow.

Tennis elbow is generally more common than golfer’s elbow, but the two have a lot in common. Both usually involve repeated gripping, twisting or lifting with the wrist, and both tend to build up gradually rather than starting with a single injury.

What people often notice

People describe a fairly consistent set of experiences with these conditions:

• Pain at the bony bump on the outer or inner elbow, sometimes spreading into the forearm
• Discomfort when gripping a kettle, opening a jar, turning a door handle or shaking hands
• Weakness in grip, such as finding a full coffee mug surprisingly hard to hold out at arm’s length
• Morning stiffness that eases with gentle use
• Tenderness when pressing directly on the bump

Other problems can cause elbow pain too, including irritation of the nerves that pass around the elbow, arthritis in the joint, bursitis at the tip of the elbow, and pain referred from the neck. Sorting out which is which starts with your provider’s history and examination.

Why a scan is not always the first step

Many people are surprised to learn that tennis and golfer’s elbow are often diagnosed without any imaging at all. A provider can usually identify them from where the tenderness is and which movements bring on the pain, such as resisted lifting of the wrist for tennis elbow or resisted curling of the wrist for golfer’s elbow.

Imaging tends to come into the picture in specific situations, for example when:

• The diagnosis is uncertain, or symptoms do not fit the usual pattern
• Pain has continued longer than expected despite the approach your provider recommended
• There is swelling or a lump that needs to be looked at
• Your provider wants to check the tendon before discussing other options or a referral
• A specific injury, such as a sudden pull while lifting, raises the question of a tear

Whether you need a scan, and which one, is your provider’s decision.

How ultrasound looks at the elbow tendons

The common extensor and flexor tendons sit just under the skin, which makes them a good fit for ultrasound. The sonographer can see the tendon where it attaches to the bone, follow it down into the muscle, and compare it with the other elbow if that is part of the request.

On ultrasound, a provider may be looking for things such as:

• Thickening of the tendon compared with what is expected or with the other side
• Changes in texture that suggest tendinopathy, where the normally organized fibres look less regular
• Small tears within the tendon
• Increased blood flow, which can be shown with a Doppler setting
• Calcium within the tendon or small irregularities on the bone surface beneath it
• Fluid around the tendon or within the joint

An elbow ultrasound can also look at nearby structures. On the inner side, the ulnar nerve runs in a groove behind the medial bump, the spot people call the “funny bone.” If your provider has asked for it, the sonographer can follow this nerve and watch whether it shifts out of its groove as you bend the elbow. On the outer side, the ligaments that stabilize the joint lie close to the extensor tendon and may be checked as well.

What ultrasound cannot see

Sound waves do not pass through bone, so the inside of the joint and the cartilage surfaces are not well seen. If your provider is concerned about arthritis, loose fragments or a fracture, an X-ray is more likely to be requested, and it is common to have both. For a broader look at how ultrasound handles tendons and ligaments elsewhere in the body, see our article on musculoskeletal ultrasound for sports injuries.

What the scan is like

An elbow ultrasound is generally a short, relaxed appointment.

1. You sit beside the exam table, often with your arm resting on the table or on a cushion.
2. For the outer elbow, the arm usually rests with the elbow bent and the thumb pointing up, or with the palm facing down.
3. For the inner elbow, you may be asked to turn the arm so the palm faces up, or to lean slightly toward the affected side.
4. The sonographer applies gel and moves a small transducer over the bony bump and along the forearm.
5. You may be asked to make small movements, such as clenching a fist, bending the wrist or slowly bending and straightening the elbow.

Pressing directly over a tender tendon can be uncomfortable. Say so if it is, and the sonographer can adjust. Wear a short-sleeved or sleeveless top so the elbow is easy to reach, bring your health card and requisition, and remove bracelets or a watch from that arm. If you wear a forearm strap or brace, take it off before the scan begins. No fasting or other special preparation is normally needed, though you should follow any instructions you are given when you book.

Reading between the lines of an elbow report

Your report is sent to the provider who requested it. Terms such as “tendinosis,” “tendinopathy,” “partial-thickness tear” or “hyperemia” (increased blood flow) are descriptions of what the images showed. They are not, on their own, a prediction of how long your symptoms will last or what treatment you need.

Tendon changes on ultrasound and the amount of pain a person feels do not always match closely. Some people with obvious changes feel relatively little discomfort, and others with modest changes are quite sore. Your provider brings together your symptoms, how they are affecting daily life and the imaging findings when discussing next steps, which may include activity changes, physiotherapy, equipment changes at work or home, or a referral.

When elbow pain should not wait

Call 911 or go to the nearest emergency department if elbow pain follows a fall or impact and the arm looks deformed, cannot be moved, or the hand becomes cold, pale or numb. Arm pain together with chest discomfort, shortness of breath, sweating or nausea also needs emergency care. A hot, red, swollen elbow with fever should be assessed promptly. If you are not sure how urgent your symptoms are, Health811 offers free advice from a registered nurse in Ontario.

Questions worth bringing to your provider

If you have been told you have tennis or golfer’s elbow, a few questions can help you understand the plan:

• Do you think imaging would change what we do next, or can we start without it?
• If a scan is ordered, what are you hoping it will show?
• Are there tasks at work or home that I should adjust while this settles?
• At what point should I come back if it is not improving?

Booking an elbow ultrasound in Ajax

When your provider has requested an elbow ultrasound, Rossland Diagnostic Clinic at Unit 102, 300 Rossland Road East in Ajax can help. We are open weekdays from 9:00am to 5:00pm and Saturdays from 8:00am to 3:30pm, with free parking on site.

Call 905-426-3111 or request an appointment online, and our team will be in touch to arrange a time.