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Adding a Transverse Scan in the Ultrasound Diagnosis of Extensor Tendinopathy

Wang, Yi-Chian MD; Lew, Rachel J.; Lee, Chia-Wei MD; Chiang, Yi-Pin MD, PhD

American Journal of Physical Medicine & Rehabilitation: May 2017 - Volume 96 - Issue 5 - p e93–e94
doi: 10.1097/PHM.0000000000000625
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From the Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan (Y-CW, C-WL); University of California, Berkeley, California (RJL); and Department of Rehabilitation Medicine, MacKay Memorial Hospital, Taipei, Taiwan (Y-PC).

All correspondence and requests for reprints should be addressed to: Yi-Pin Chiang, MD, PhD, No. 92, Sec. 2, Zhongshan N Rd, Taipei City 10449, Taiwan.

No funding was received for this work.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported bythe authors or by any individuals in control of the content of this article.

This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this feature will change and enhance the learning experience.

Walter R. Frontera, MD, PhD



Extensor tendinopathy ("tennis elbow") is a common term used to describe pathology of the forearm extensor tendons that converge to anchor the muscles to the lateral elbow. During traditional ultrasonography using the longitudinal scanning method,1 it is difficult to determine which component of the common extensor tendon (CET) is affected. We propose the addition of a transverse scan to better visualize the tendons that join and form the CET. The attached video illustrates findings from both longitudinal and transverse scanning methods.

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Since the longitudinal method was previously published by Chiang et al.,1 the transverse approach is described below:

  • (1). First, the upper arm is internally rotated to bring the lateral epicondyle upward, with the forearm pronated 90 degrees. The patient is instructed to make a fist to further tighten the CET, with the dorsal wrist joint facing upward and at maximal flexion.2 The probe is placed transversely at the middle of the dorsal forearm.
  • (2). The extensor digiti minimi (EDm) is verified by having the client move his or her fifth finger. The remaining muscles (extensor carpi ulnaris (ECU), extensor digiti communis (EDc), and extensor carpi radialis brevis (ECRB)) are sequentially identified by their relative positions to the EDm from the ulnar to the radial side.
  • (3). Moving the probe proximally, one can see the oval-shaped EDm muscle fibers converge to form the EDm tendon, beneath the EDc muscle. When the probe reaches the radial head, the annular ligament is appreciated as a thin, rainbowlike hyperechoic structure wrapping around the radial head.
  • (4). After crossing the radiohumeral joint, the EDc muscle converges to form the EDc tendon. This joins the tendons of the other muscles to form the CET.
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In Figure 1A, the longitudinal view showed a slitlike, small partial thickness CET tear. In Figure 1B, the transverse view revealed a large tear at radial side of CET, almost occupying the full width of ECRB. As a result of this additional finding, we postponed eccentric strengthening for this patient3 and prescribed a wrist splint to prevent strenuous ECRB contraction. In Figure 2A, the longitudinal view showed full-thickness, hypoechoic change and swelling of CET, suggestive of tendinosis and scattered internal tears. However, the transverse view (Fig. 2B) demonstrates that the tendinosis involved mainly the ECU tendon, and the ECRB tendon was intact. The patient was a frequent user of screwdrivers and had prominent ECU muscle activity and wrist ulnar deviation when performing forceful wrist extension and fingers grasping. We prescribed a special wrist splint to prevent overt wrist ulnar deviation and initiated a strengthening program specific to the ECRB. In both cases, the transverse scan of the CET offered useful information for clinical prescription.





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In this article, we proposed the addition of a transverse scan to better visualize and track the structures that converge to form the CET. The findings helped to provide modifications of specific wrist and hand activities to prevent further injury and facilitate recovery.

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1. Chiang YP, Hsieh SF, Lew HL: The role of ultrasonography in the differential diagnosis and treatment of tennis elbow. Am J Phys Med Rehabil 2012;91:94–5
2. Wang YC: Chapter 3: Elbow, in Wang TG, Chen WS, Wang YC, et al (eds): Musculoskeletal Ultrasound Examination, 1st ed. Taipei, Taiwan, The Leader Book Company, 2014, 91–101
3. Raman J, MacDermid JC, Grewal R: Effectiveness of different methods of resistance exercises in lateral epicondylosis—a systematic review. J Hand Ther 2012;25:5–25
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