ACR Appropriateness Criteria®
Clinical Condition: Chronic Elbow Pain
Variant 1: Suspect intra-articular osteocartilaginous body; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MR arthrogram, elbow |
9 |
Either method is appropriate. Depends on availability, expertise, and local conditions. If effusion is present, without contrast is preferred. |
MRI, elbow, routine |
9 |
Either method is appropriate. Depends on availability, expertise, and local conditions. If effusion is present, without contrast is preferred. |
CT, elbow |
8 |
If double contrast is used, dose of less than 0.5 cc of contrast should be used. |
Tomography, elbow |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Suspect occult injury; e.g., osteochondral injury; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, elbow, routine |
9 |
|
MR arthrogram, elbow |
2 |
|
CT, elbow |
2 |
|
Tomography, elbow |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Suspect unstable osteochondral injury; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MR arthrogram |
9 |
Either MR arthrogram or MR routine is appropriate. Depends on availability, expertise, and local conditions. |
MRI, elbow, routine |
9 |
Either MR arthrogram or MR routine is appropriate. Depends on availability, expertise, and local conditions. |
CT, elbow |
2 |
|
Tomography, elbow |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Suspect nerve entrapment or mass; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, elbow, routine |
9 |
|
US, elbow |
5 |
An alternative to MRI if expertise is available. |
No imaging indicated |
2 |
|
CT, elbow |
2 |
|
NUC, bone scan |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Suspect chronic epicondylitis; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, elbow, routine |
9 |
|
US, elbow |
5 |
An alternative to MRI if expertise is available |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 6: Suspect collateral ligament tear; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MR arthrogram, elbow |
9 |
Either MR arthrogram or MR routine is appropriate. Depends on availability, expertise, and local conditions. |
MRI, elbow, routine |
9 |
Either MR arthrogram or MR routine is appropriate. Depends on availability, expertise, and local conditions. |
US, elbow |
5 |
An alternative to MRI if expertise is available. |
CT, elbow |
2 |
|
X-ray, elbow, stress |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 7: Suspect biceps tendon tear and/or bursitis; radiographs nondiagnostic.
Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
MRI, elbow, routine |
9 |
|
US, elbow |
5 |
An alternative to MRI if expertise is available. |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Osteochondral Lesion or Intra-articular Osteocartilaginous Body
Radiographs are required before other imaging studies and may be diagnostic for osteochondral fracture, osteochondritis dissecans, and osteocartilaginous intra-articular body (IAB). Tomography, single-contrast (iodinated contrast or air) and double-contrast (iodinated contrast and air) arthrography with or without computed tomography (CT), and CT alone have been used for detecting an osteochondral lesion or IAB. All of these studies have limitations; a small IAB may be obscured by contrast or confused with air bubbles (double-contrast arthrography). A CT air arthrogram can avoid confusion of air bubbles with IABs. More recently, magnetic resonance imaging (MRI) has been advocated as the initial study for suspected osteochondral fracture or IAB. Regardless of method, detection of an IAB is limited by its size and location within the elbow joint. Detection of IAB is enhanced by the presence of joint effusion. Direct intra-articular magnetic resonance arthrography (MRA) is preferred to routine MRI for diagnosis of IAB and may also play a role in improving diagnosis of stability of the osteochondral lesion.
Tendon, Ligament, Muscle, Nerve, or Other Soft-Tissue Abnormality
Radiographs can be useful to identify heterotopic calcification (ossification) of the ulnar collateral ligament. This finding may be associated with partial or complete tears of that structure. Avulsion of the ulnar collateral ligament at the insertion site on the ulna is a source of chronic medial elbow pain in the throwing athlete. This finding is best evaluated with a combination of radiographs and coronal MRI. MRI may provide important diagnostic information for evaluating the adult elbow in many different conditions, including collateral ligament injury, epicondylitis, injury to the biceps and triceps tendons, and abnormality of the ulnar, radial, or median nerve, and for evaluating masses about the elbow joint. There is a lack of studies showing the sensitivity and specificity of MRI in many of these cases; most of the studies demonstrate MRI findings in patients either known or highly likely to have a specific condition. Ultrasound (US) has been shown to be helpful for diagnosing complete and partial tears of the distal biceps tendon, flexor and extensor tendons, and ligaments, providing an alternative to MR imaging.
With use of appropriate pulse sequences, MRI is an effective tool in the preoperative diagnosis of posterolateral rotatory instability. This includes assessment of the ulnar band of the lateral collateral ligament. Magnetic resonance arthrography has been advocated to distinguish complete tears from partial tears of the medial collateral ligament. Epicondylitis--lateral ("tennis elbow") or medial (in pitchers, golfers, and tennis players)--is a common clinical diagnosis, and MRI is usually not necessary. MRI may be useful for confirming the diagnosis in refractory cases and to exclude associated tendon and ligament tear.
Bicipitoradial and interosseous bursitis around the distal biceps tendon is a source of elbow pain that can be assessed with MRI or ultrasound. MRI also demonstrates the effects of the bursa on adjacent structures including the posterior interosseous and median nerves.
The ulnar nerve is particularly vulnerable to trauma from a direct blow in the region of its superficial location in the restricted space of the cubital tunnel. Anatomic variations of the cubital tunnel retinaculum may contribute to ulnar neuropathy. Axial T1-weighted images have been shown to depict the size and shape of the nerve, and axial T2-weighted or STIR images may show increased signal in the presence of neuritis. A snapping of the medial head of the triceps can cause recurrent dislocation of the ulnar nerve. This diagnosis can be confirmed with MRI or CT using axial images with the elbow in flexion and extension. Ultrasound can also be used for confirmation of snapping triceps and for evaluating the ulnar nerve. Radial nerve and median nerve entrapment syndromes may also be evaluated with MR imaging.
Abbreviations
- CT, computed tomography
- MR, magnetic resonance
- MRI, magnetic resonance imaging
- NUC, nuclear medicine
- US, ultrasound