Dynamic microvascular imaging with provocative testing in lateral epicondylitis: associations with tendon vascularity and clinical severity

Purpose: This study aims to investigate whether dynamic microvascular imaging (MVI) performed during mechanical provocation provides added diagnostic value in the ultrasound evaluation of lateral epicondylitis and explore its relationship with pain severity and functional impairment. Materials and Methods: This retrospective study included 94 patients with unilateral chronic lateral epicondylitis. Each symptomatic elbow was compared with the contralateral asymptomatic elbow. All patients underwent gray-scale ultrasound, Power Doppler (PD), and MVI at rest during mechanical provocation. Common extensor tendon thickness, structural abnormalities, and intratendinous vascularity were evaluated. Pain severity was assessed using a visual analogue scale (VAS), and functional impairment was evaluated using the Patient-Rated Tennis Elbow Evaluation (PRTEE). Results: Symptomatic elbows demonstrated significantly greater common extensor tendon thickness compared with contralateral asymptomatic elbows (5.29 ± 0.45 mm vs. 4.43 ± 0.41 mm). Structural tendon abnormalities were observed in 40.0% of symptomatic elbows. Following mechanical provocation, intratendinous vascularity increased on both modalities; however, MVI demonstrated more extensive and clearly delineated vascular signals compared with PD. Higher post-provocation vascularity grades were significantly associated with increased VAS and PRTEE scores. Conclusion: Dynamic MVI during mechanical provocation provides additional diagnostic value beyond static ultrasound assessment in lateral epicondylitis and demonstrates meaningful associations with pain severity and functional impairment.