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. 2024 May 11;15(1):113.
doi: 10.1186/s13244-024-01695-8.

Assessing the treatment response of lateral elbow tendinopathy using time-dependent ultrasonography, Doppler imaging, and elastography

David Tobaly  1 , Patrice Tétreault  2 , Guy Cloutier  3 , Manon Choinière  3   4 , Philippe Grondin  2 , Véronique Freire  5 , Anne-Sophie Julien  6 , Nathalie J Bureau  7   8
Affiliations

Assessing the treatment response of lateral elbow tendinopathy using time-dependent ultrasonography, Doppler imaging, and elastography

David Tobaly et al. Insights Imaging. .

Abstract

Objective: To investigate the structural alterations, neovascularity, and elasticity of tendons and the relationship between elasticity and the Patient Rated Tennis Elbow Evaluation score after undergoing US-guided fenestration or surgery in patients with chronic lateral elbow tendinopathy.

Methods: Participants from the per-protocol population of a randomized trial conducted between October 2016 and June 2020 were included. The surgery and fenestration groups included 24 (mean age, 50 ± 7 years [standard deviation], 10 men) and 29 (47 ± 8 years, 18 men) participants, respectively. Ultrasound exams were performed at baseline, 6 months, and 12 months. Statistical analyses included linear mixed effects and generalized equation estimation models.

Results: Fenestration had no significant impact on tendon thickness (p = 0.46). Conversely, surgery significantly increased tendon thickness at 6 months (p < 0.0001) and remained elevated at 12 months (p = 0.04). Tendon echostructure exhibited a group effect (p = 0.03), indicating a higher proportion of pathological scores in the surgery group post-intervention compared to the fenestration group. Both groups showed a similar reduction in neovascularity from 6 to 12 months postintervention (p = 0.006). Shear-wave velocity increased in the fenestration group at 6 months (p = 0.04), while the surgery group experienced a nonsignificant decrease at 6 months, with some improvement at 12 months (p = 0.08). Changes in shear-wave velocity did not correlate with clinical outcome.

Conclusions: Fenestration and surgery reduced tendon neovascularity over time. Unlike surgery, fenestration did not impact tendon size while improving tendon echostructure and elasticity.

Critical relevance statement: Fenestration and surgery equally alleviated symptoms and decreased tendon neovascularity in lateral elbow tendinopathy; however, fenestration did not alter tendon thickness and improved echostructure and shear-wave velocity, suggesting shear-wave velocity's potential for quantitatively monitoring tendon elasticity during healing.

Key points: Reliable markers for monitoring healing response and informing treatment protocols in elbow tendinopathy are lacking. Fenestration and surgery reduced tendon neovascularity, while fenestration improved tendon echostructure and shear-wave velocity. Shear-wave velocity may provide quantitative measures to monitor tendon elasticity in response to treatment.

Keywords: Dry needling; Elastography; Tendinopathy; Tennis elbow; Ultrasonography (Doppler).

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Conflict of interest statement

NJB was supported by a research scholarship from the Fonds de Recherche du Québec—Santé (FRQ-S) and the Fondation de l’Association des Radiologistes du Québec (FRQS-ARQ #266408), and she received a loan of the ACUSON S3000 ultrasound machine (Siemens Healthcare) for the duration of this project. GC has received equipment loans and funding from Siemens Healthcare. The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Ultrasound of the right elbow in a 49-year-old man with chronic lateral tendinopathy. a The thickness of the common extensor tendon and radial collateral ligament complex (between the cursors) is measured on a long-axis US, showing the minor groove (arrow) at the base of the lateral epicondyle. b The entire tendon was scanned to assess its echostructure. On a more anterior image, the tendon is thickened and hypoechoic and shows anechoic clefts (arrow) consistent with an echostructure grade 3. H, humeral epicondyle; R, radial head
Fig. 2
Fig. 2
Power Doppler imaging of the right elbow in the same 49-year-old man with chronic lateral tendinopathy. The entire tendon was scanned, capturing the area with the highest neovessel density. a Baseline long-axis US with Power Doppler imaging reveals pixels of Doppler signal covering around 50% of the tendon surface, indicating Grade 2 neovascularity. b Following tendon fenestration treatment, the 6-month follow-up long-axis US displays partial neovessel regression, with a few pixels of Doppler signal indicating Grade 1 neovascularity. c The 12-month follow-up long-axis US exhibits a nearly complete resolution of the Doppler signal (Grade 1 neovascularity)
Fig. 3
Fig. 3
SWE of the right elbow in the same 49-year-old man with chronic lateral tendinopathy. a Baseline long-axis SWE of the common extensor tendon and radial collateral ligament complex shows the ROI. b Corresponding VTIQ parametric velocity map with three equidistant ROI placed within the tendon, aligned from the apex to the base of the epicondyle to measure the local SWVs. The mean SWV was 5.55 m/s. c At the 6-month follow-up exam, the mean SWV was 8.29 m/s. d At the 12-month follow-up exam, the mean SWV was 9.15 m/s
Fig. 4
Fig. 4
Tendon thickness over time in the same 49-year-old man with chronic lateral tendinopathy. This graph presents the mean tendon thickness over time, measured in centimetres, with their corresponding CI intervals in parentheses and displayed by the bars. Surgery significantly increased tendon thickness, whereas fenestration did not alter it significantly. Statistically significant differences between intervention groups were observed at 6 months (p < 0.0001) and 12 months (p = 0.003)
Fig. 5
Fig. 5
Tendon echostructure and neovascularity pathological scores over time in the same 49-year-old man with chronic lateral tendinopathy. a This graph presents percentages of pathological tendon echostructure scores (grades 2, 3, and 4) over time, with CI intervals in parentheses and represented by bars. The surgery group exhibited more structural alterations persisting over time than the fenestration group (p = 0.03), while the fenestration group showed potential long-term improvement. b The graph displays percentages for pathological neovascularity scores (grades 2 and 3) over time, with CI intervals in parentheses and represented by bars. Both interventions significantly reduced neovessel density between 6 and 12 months postintervention (p = 0.006). Although the fenestration technique appeared to achieve faster and greater reduction, there was no difference between intervention groups (interaction p = 0.46)
Fig. 6
Fig. 6
Tendon SWV over time in the same 49-year-old man with chronic lateral tendinopathy. The graph illustrates the mean SWV over time in meters per second, with CI intervals in parentheses and displayed by the bars. Tendon fenestration significantly increased tendon SWV (p = 0.03), peaking 6 months postintervention. Conversely, SWV tended to decrease in the open-surgery group at 6 months, with slight improvement at 12 months, but these changes did not reach statistical significance (p = 0.08). The group difference was significant at 6 months (p = 0.03) but not at 12 months (p = 0.56)
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