title: The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review.
abstract: BACKGROUND
  Ultrasound is considered a reliable, widely available, non-invasive and inexpensive imaging technique for assessing soft tissue involvement in Lateral epicondylalgia. Despite the number of diagnostic studies for Lateral Epicondylalgia, there is no consensus in the current literature on the best abnormal ultrasound findings that confirm lateral epicondylalgia.
  
  
  METHODS
  Eligible studies identified by searching electronic databases, scanning reference lists of articles and chapters on ultrasound in reference books, and consultation of experts in sonography. Three reviewers (VCDIII, KP, KW) independently searched the databases using the agreed search strategy, and independently conducted all stages of article selection. Two reviewers (VCDIII, KP) then screened titles and abstracts to remove obvious irrelevance. Potentially relevant full text publications which met the inclusion criteria were reviewed by the primary investigator (VCDIII) and another reviewer (CGS).
  
  
  RESULTS
  Among the 15 included diagnostic studies in this review, seven were Level II diagnostic accuracy studies for chronic lateral epicondylalgia based on the National Health and Medical Research Council Hierarchy of Evidence. Based from the pooled sensitivity of abnormal ultrasound findings with homogenous results (p > 0.05), the hypoechogenicity of the common extensor origin has the best combination of diagnostic sensitivity and specificity. It is moderately sensitive [Sensitivity: 0.64 (0.56-0.72)] and highly specific [Specificity: 0.82 (0.72-0.90)] in determining elbows with lateral epicondylalgia. Additionally, bone changes on the lateral epicondyle [Sensitivity: 0.56 (0.50-0.62)] were moderately sensitive to chronic LE. Conversely, neovascularity [Specificity: 1.00 (0.97-1.00)], calcifications [Specificity: 0.97 (0.94-0.99)] and cortical irregularities [Specificity: 0.96 (0.88-0.99)] have strong specificity for chronic lateral epicondylalgia. There is insufficient evidence supporting the use of Power Doppler Ultrasonogrophy, Real-time Sonoelastography and sonographic probe-induced tenderness in diagnosing LE.
  
  
  CONCLUSIONS
  The use of Gray-scale Ultrasonography is recommended in objectively diagnosing lateral epicondylalgia. The presence of hypoechogenicity and bone changes indicates presence of a stressed common extensor origin-lateral epicondyle complex in elbows with lateral epicondylalgia. In addition to diagnosis, detection of these abnormal ultrasound findings allows localization of pathologies to tendon or bone that would assist in designing an appropriate treatment suited to patient's condition.
authors.affiliation: International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia. DONVC001@mymail.unisa.edu.au.
authors.forename: Valentin C
authors.initials: VC
authors.lastname: Dones
authors.forename: Karen
authors.initials: K
authors.lastname: Grimmer
authors.forename: Kerry
authors.initials: K
authors.lastname: Thoirs
authors.forename: Consuelo G
authors.initials: CG
authors.lastname: Suarez
authors.forename: Julie
authors.initials: J
authors.lastname: Luker
mesh_terms: D050280:Arm Bones / Q000000981:diagnostic imaging* / Q000473:pathology*; D003952:Diagnostic Imaging / Q000295:instrumentation / Q000379:methods*; D054459:Elasticity Imaging Techniques; D006801:Humans; D015203:Reproducibility of Results; D013716:Tennis Elbow / Q000175:diagnosis* / Q000000981:diagnostic imaging; D018608:Ultrasonography, Doppler; D054928:Validation Studies as Topic