When Do You Need An MRI For Golfer’s Or Tennis Elbow?

What Can Magnetic Resonance Imaging Show? And What Do Those Results Actually MEAN?

I’m often asked by my clients if I think they should get an MRI of their elbow – Particularly if they’ve been suffering from Tennis or Golfer’s Elbow for several months or longer.

You may be wondering whether you need an MRI for diagnosis and when the right time to get one is, so, here’s a guide to help you figure it out and decipher the medical jargon results.

Outline / Table Of Contents

(Click any of the links below to skip down to that section.)

1. Do I need an MRI to diagnose my Golfer’s or Tennis Elbow?
2. When IS the right time to get an MRI – If at all!?
3. What will an MRI show?
4. And what to the results actually mean?
5. Another option: The Sonogram
6. Conclusions / summing up

It’s true that Magnetic Resonance Imaging (MRI) is the gold standard when it comes to imaging or “seeing” what’s wrong with soft tissues, like muscles, tendons and ligaments.

If there are any significant defects in your tendons (or nearby elbow ligaments) an MRI will reveal these in the greatest detail currently available in modern medicine…

But how valuable will this information be to you?

Your initial assumption is probably that it will be very useful information to have – but, in fact, that’s NOT a given, depending on what we’re about to cover…

And you probably don’t want to waste your time and take the trouble to do something that’s ultimately unnecessary, since there’s a lot involved in getting an MRI…

1. You first have to see your Orthopedist and get the authorization, then make an appointment, travel to a hospital or MRI facility…
   
   
2. It can take hours out of your day. You may need to spend a long time waiting at the facility…
   
   
3. It’s often an unpleasant experience, considering the loud noise and the constraining position you may have to be in…
   
   
4. And then there’s the cost, which will be substantial if not covered by insurance or may still include a sizable copay even if covered.

The ultimate question to consider before going through all the trouble, though, is:

Will the results fundamentally change your treatment strategy or alter your daily activities?

The short answer is that an MRI is probably neither necessary nor useful for most early and mid-term Tennis and Golfer’s Elbow sufferers (and even some chronic / long-term sufferers, who don’t intend to consider surgery.)

First of all, it’s definitely not necessary early on…

Why You Don’t Need An MRI For Initial Diagnosis

In this era of high-tech medical advances, it can be enticing to immediately reach for the latest treatment or diagnostic scan!

But an MRI is not necessary whatsoever for the basic diagnosis of Golfer’s or Tennis Elbow.

And most Doctors will be very unlikely to order one for you in the early stages / weeks / months of your elbow tendon condition.

(The nature and location of your symptoms plus a simple resistance test or two is all it takes to diagnose these conditions.)

When IS The Right Time To Get An MRI?

When it starts to become truly necessary is when you’ve been a long-term sufferer (often 6 months to 2 years) who is at the point of considering surgery.

For more on this question, here’s an article devoted to that:

When IS it time to consider surgery? Article / video

Otherwise, it’s not likely to dramatically change the focus, strategy or tactics of your treatment – Especially if you’re not ready to consider surgery.

And there IS another way to “take a look” and image the soft tissues of your elbow a lot more easily and in real time without an expensive and inconvenient trip to the MRI center or hospital – IF you feel you need some objective measure of what’s wrong with your elbow.

That option is a Sonogram, also known as a Diagnostic Ultrasound, and we’ll return to that subject later in this article.

However, an MRI is most definitely a prerequisite for having surgery, so if you are at your wits end after suffering for a year or longer and are about to meet with an Orthopedist, they may order and MRI for you to see if you’re a good candidate for it.

So, let’s explore what an MRI can show (and why it probably isn’t worth the trouble or useful if you’re not already considering surgery)

What Will An MRI Of The Elbow Show?

An MRI (Magnetic Resonance Imaging) can visualize problems with the bones, joints and nerves of the elbow as well as a host of other changes to soft tissues, like muscles, tendons and ligaments.

(Although, when it comes to visualizing defects in bones and their joints, like fractures, Xray imaging is superior.)

Once an MRI is taken, a Radiologist (a specialist who interprets medical images) will interpret the scan and write/dictate a report of their findings, an essential step in the process.

In the video above, a Radiologist from First Look MRI describes what he sees in the MRI of a Tennis Elbow patient, explaining that there are negative changes to be seen in the tendon but that this is probably not a case for surgery – at least not yet.

“…so, it’s a challenge to describe it appropriately so they don’t do surgery unnecessarily – and they don’t give conservative treatment when they really should go in there and fix it.”

‘Lateral Epicondylitis Elbow’ – First Look MRI | Youtube

The main areas of concern (but not the only areas that may be a source of elbow pain) in Tennis Elbow and Golfer’s Elbow are the tendons connecting to the inner and outer elbow.

The ‘Common Extensor Tendon Origin’ – is the location of Tennis Elbow (Tendons attaching to the outer elbow / Lateral Epicondyle)

The ‘Common Flexor Tendon Origin’ – is the location of Golfer’s Elbow (Tendons attaching to the inner elbow / Medial Epicondyle)

The primary problems / dysfunctions with these tendons include:

• Tendon degeneration / ‘Tendinosis’ (very common / typical)
• Abnormal thickening of the tendon (common)
• Inflammatory changes / Tendonitis (less common)
• Tendon Calification ‘Calcific Tendinosis’ (less common)
• Tendon tears (less common)
• And bone spurs / ‘Enthesophites’ (rare)

One of the reasons why it may not be useful to discover via MRI that you have one or more of these abnormalities, is that they are not entirely unknown in the pain-free population.

In other words, there isn’t a 100% reliable cause-and-effect relationship between all of these abnormalities and pain.

A certain amount of degenerative change happens in all tissues as we age.

It’s a fact of life that our tissues gradually degrade as we get older.

You can see this in people’s faces! The wrinkles and sagging skin are a sign of collagen and elastin loss and degradation (and loss of hydration.)

Yes, the more severe the changes, the more likely they are to be a source of pain – especially major tears – BUT…

Even tears are not conclusive. There a people with tears – even complete ruptures of some tissues that are completely pain free.

(This phenomenon is more likely to occur in other torn tissues like menisci, labrums and ligaments but still includes tendons in some cases.)

Milder tears can heal. Some moderate tears can heal. Major tears likely won’t heal – but short of that, mild to moderate tears don’t necessarily HAVE to heal – or heal completely in order for you to get out of pain.

Another reason this information may not be helpful (if you haven’t decided to have surgery) is that, in all likelihood, your treatment and rehab won’t change significantly.

Chances are, if you’ve already decided not to have surgery – OR to do everything in your power to heal and recover before considering the last resort of surgical intervention…

Then you’re probably going to continue with the same treatment and exercise protocol regardless of what the MRI shows.

Although you might change your approach based on the observation that what you’ve been doing up to this point hasn’t been effective and the belief that you need to try something different!

This is especially true if you’re considering Prolotherapy, Stem Cell Therapy or Platelet-Rich Plasma Therapy as the next step to treating your Tennis or Golfer’s Elbow.

BUT, an MRI is not required nor is it a standard protocol to receive one prior to having these injection procedures!

These procedures are often preceded by an Ultrasound / Sonogram “screening” of your elbow by your Orthopedist.

And these procedures are usually conducted under real-time Sonogram scanning to locate the damaged areas and target the injections – at least with PRP and Stem Cell treatments. (More on Sonogram shortly.)

So, let’s delve deeper into what all these abnormal things that can be seen on an MRI actually mean – especially if you will be considering surgery soon or you’ve already had an MRI.

What Do My MRI Results Actually MEAN?

One of the most critical points to understand is that the vast majority of dysfunctional changes seen on MRIs with Tennis and Golfer’s Elbow are chronic and degenerative – NOT acute and inflammatory.

This is an area of profound confusion, because even top-notch medical websites still refer to Tennis and Golfer’s Elbow as forms of ‘Tendonitis’ or ‘Epicondylitis,’ which suggests an inflammatory condition (which is not accurate most of the time.)

(These “-itis” suffix terms have become so widely used and entrenched in the medical lexicon they have become “placeholders” for a wide range of conditions / pathologies – They are junk terms to a large extent. Tendinopathy is a much better general term.)

And the same sources usually discuss the “treating” (suppression) of inflammation as a necessary and useful treatment for these conditions.

The problem is that these conditions may involve traces of inflammation (which, keep in mind, is a natural aspect of the healing response) – especially in their early stages…

However, once these conditions become chronic (persistent / long-term, as in months rather than weeks, in this case) the medical research shows these conditions almost always become degenerative.

This research goes back decades and is continuously reinforced by an ever-increasing number of MRI scan records demonstrating proof of tendon degeneration in present and recent cases.

Here is a direct, technical terminology-heavy quote from RadioPaedia on the pathology of Tennis Elbow, which we’ll break down and explore in detail:

“It is thought that repetitive stress and overuse leads to tendinosis involving the origin of the extensor tendons at the lateral elbow, with microtearing and progressive degeneration due to an immature reparative response that may progress to a full-thickness tendon tear. Alternatively, it may also result from direct trauma.”

Lateral Epicondylitis “an overuse syndrome of the common extensor tendon”

– Radiopaedia .org

What this means is that Tennis Elbow is usually thought to be a gradual (chronic) condition (repetitive stress / overuse happens slowly over time) although it can sometimes be the result of direct trauma.

‘Direct trauma’ – means a sudden, forceful event / ‘Acute Trauma,’ like what would result from a fall, impact or other sports or accident-related injury, but this is actually on the rare side when it comes to Tennis and Golfer’s Elbow.

”Tendinosis’ – is the operative word and the most common finding seen on MRIs. It essentially means decay; a degenerative breakdown of the tendon.

‘Microtearing and progressive degeneration’ – is basically synonymous with Tendinosis. (Focus on the MICRO, meaning microscopic, in ‘microtearing’ – ‘Fraying’ is another way of saying it.)

‘Due to an immature reparative response’ – means that the body’s attempts to heal and repair the tendon is failing; it’s not maturing and progressing as it should. (This is also the hallmark of Tendinosis.)

What’s happening is the collagen protein that the tendon is mostly composed of is degrading, becoming increasing disorganized (not well-aligned and parallel as it should be) and weaker.

‘Tendon Thickening’ – is another term often seen on MRI reports. This is another chronic, dysfunctional (degenerative) state that often occurs to tendons under abnormal loads.

‘Calcific Tendonitis / Tendinosis’ – is a less common, more advanced degenerative change sometimes seen in elbow tendons (much more common in the Rotator Cuff tendons of the shoulder)

‘Tearing’ – of the tendon fibers can sometimes be the eventual result from these conditions which weaken the tendon over months or years.

But significant tears necessitating surgery (or that seem to make a strong case for it) are more rare than one might think.

Some degree of Tendinosis, from mild, moderate to severe is the most likely observation and assessment the Radiologist will make in the MRI report.

And Tendinosis (as opposed to Tendonitis/Tendinitis) along with most of the other diagnosis terms, like thickening are, again, synonymous with gradual degeneration – Not usually sudden, acute traumas.

Ultrasound: The Other Imaging Option

There IS another, faster, cheaper, easier option to the MRI scan (or prelude to it) that you should know about and potentially push for first, however…

And that option is the Sonogram or Diagnostic Ultrasound.

This type of imaging scan uses sound waves like the ‘Therapeutic Ultrasound’ that you might receive to treat your Golfer’s or Tennis Elbow in a Physical Therapy / Physiotherapy clinic.

However, ‘Diagnostic Ultrasound’ involves using sound waves to generate an image in real time on a computer monitor for diagnostic rather than for treatment purposes. (Like in fetal health checks.)

It’s not as clear and detailed as an MRI but in areas where the tendon or other tissue is close to the surface of the body (like the elbow) it can produce a very reliable image.

(And has improved significantly since this article was written.)

When this technology best comes into play for Tennis and Golfer’s Elbow is as a screening tool.

An Orthopedic Surgeon would not likely rely on Sonogram results to perform surgery…

But a Sonogram can be used to rule out significant tears and save you from the need to have an MRI.

• If there is no evidence of a tear in the Sonogram scan = No need for an MRI
  
  
• If there IS evidence of a tear = An MRI can be done to and image it in better detail and confirm the suitability of surgery.

This does not seem to be very common practice in surgical clinic settings in the United States, however. (It may be in Europe)…

But in a fairly recent Polish medical study, (published in July of 2017) designed to compare the efficacy and reliability of Ultrasound compared to MRI…

Researchers demonstrated that the Diagnostic Ultrasound may be a reliable screening tool for detecting tendon tears in Tennis Elbow patients.

“Conclusion: Ultrasonography is a valuable imaging modality that can be used as a screening tool to exclude high-grade CET [Common Extensor Tendon] tear in chronic LE [Lateral Epicondylitis (Tennis Elbow)] patients. Once a tear is evident on US, MRI should be considered to assess precisely the extent of tendon injury.”

Ultrasonography Versus Magnetic Resonance Imaging In Detecting And Grading Common Extensor Tendon Tear In Chronic Lateral Epicondylitis

https://pubmed.ncbi.nlm.nih.gov/28749994/

(I’ve been pondering this for years, wishing that Orthopedists would offer this to their patients on the first visit – potentially saving them from the hassle and expense of an MRI.)

Conclusions: What It All Comes Down To

So, there’s no need to rush out and get MRI for your Tennis or Golfer’s Elbow early on.

1. You don’t need it for diagnosis,
2. And what it IS likely to tell you won’t likely change your actions…
3. At least not in the early stages of your injury or early time frame (up to a year)

It doesn’t usually become truly necessary until you’ve exhausted all your conservative treatment options.

You probably want to be of the mindset that you’re ready to have surgery if the MRI confirms a major tear or other significant damage that warrants surgical intervention.

If you’re not yet at that point but you’ve been struggling with your injury for 6 months to a year or longer and strongly feel the need for SOME objective measure of how severe your tendon injury truly is…

Especially if you’re considering one of the injection therapies (Prolo, PRP, Stem Cell Therapy)…

Then a Sonogram / Diagnostic Ultrasound may be a much better, easier, cheaper alternative – at least as a screening tool or interim measure.

This article originally appeared on my Tennis Elbow Classroom site:

Article on MRIs for Tennis and Golfer’s Elbow