***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE The aim of this prospect i ve study was to compare the sensitivity and specificity of sonography with those of MRI in evaluating epicondylitis . METHODS The affected elbows of 11 patients with suspected epicondylitis were examined sonographically , and the contralateral ( normal ) elbow was also examined for comparison . In 10 of these patients , the affected elbow was also examined with MRI . In addition , both elbows of 6 volunteers without epicondylitis were examined sonographically ; 1 elbow of each volunteer was design ated as the " test " elbow and was examined with MRI . The sonograms of the patients ' affected elbows and the volunteers ' test elbows were paired with the sonograms of the contralateral elbows for comparison and were r and omly shown twice to 2 readers . These readers , working independently and without knowledge of the findings of MRI , were instructed to state whether each elbow was normal or affected by epicondylitis . The MRI scans were then shown to the readers for similar review . RESULTS Sonographic features of epicondylitis included outward bowing of the common tendon , presence of hypoechoic fluid subadjacent to the common tendon , thickening , decreased echogenicity , and ill-defined margins of the common tendon . Sensitivity for detecting epicondylitis ranged from 64 % to 82 % for sonography and from 90 % to 100 % for MRI .  Specificity ranged from 67 % to 100 % for sonography and from 83 % to 100 % for MRI . CONCLUSIONS Sonography is as specific but not as sensitive as MRI for evaluating epicondylitis . Used as an initial imaging tool , sonography might be adequate for diagnosing this condition in many patients , thus allowing MRI to be reserved for patients with symptoms whose sonographic findings are normal PURPOSE To determine the sensitivity and specificity of ultrasonography ( US ) in the detection of lateral epicondylitis and identify the US findings that are most strongly associated with symptoms . MATERIAL S AND METHODS Internal review board approval was obtained for retrospective review of the patient images , and the need for informed consent was waived . Internal review board approval was also obtained for scanning the 10 volunteers , all of whom gave informed consent . The study was compliant with the Health Insurance Portability and Accountability Act . US of the common extensor tendon was performed in 20 elbows in 10 asymptomatic volunteers ( six men , four women ; age range , 22 - 38 years ; mean age , 29.6 years ) and 37 elbows in 22 patients with symptoms of lateral epicondylitis ( 10 men , 12 women ; age range , 30 - 59 years ; mean age , 46 years ) . Fifty-seven representative images , one from each elbow , were r and omly assorted and interpreted by three independent readers who rated each common extensor tendon as normal or abnormal . Abnormal images were further classified as demonstrating one or more of eight US findings . Readers interpreted each image at two separate sessions to determine intrareader variability . The authors calculated the sensitivity and specificity of US in the diagnosis of lateral epicondylitis and the odds ratio for each US finding . Odds ratios were considered statistically significant at P < .05 when 95 % confidence intervals did not include one . RESULTS Sensitivities of US  in the detection of symptomatic lateral epicondylitis ranged from 72 % to 88 % and specificities from 36 % to 48.5 % . Odds ratios for the following findings were statistically significant ( P < .05 ) for both reading sessions : calcification of common extensor tendon , tendon thickening , adjacent bone irregularity , focal hypoechoic regions , and diffuse heterogeneity . Odds ratios for lateral epicondyle enthesophytes were statistically significant ( P < .05 ) for the first reading session only . Odds ratios for linear intrasubstance tears and peritendinous fluid were not statistically significant . CONCLUSION US of the common extensor tendon had high sensitivity but low specificity in the detection of symptomatic lateral epicondylitis . The relationship between symptoms and intratendinous calcification , tendon thickening , adjacent bone irregularity , focal hypoechoic regions , and diffuse heterogeneity was statistically significant OBJECTIVES Following a consensus statement from a multidisciplinary UK workshop , a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb . The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting . METHOD 43 consecutive referrals to a soft tissue rheumatism clinic ( group 1 ) and 45 subjects with one of a list of specific upper limb disorders ( including shoulder capsulitis , rotator cuff tendinitis , lateral epicondylitis and tenosynovitis ) ( group 2 ) , were recruited from hospital rheumatology and orthopaedic outpatient clinics . All 88 subjects were examined by a research nurse ( blinded to diagnosis ) , and everyone from group 1 was independently examined by a rheumatologist . Between observer agreement was assessed among subjects from group 1 by calculating Cohen 's κ for dichotomous physical signs , and mean differences with limits of agreement for measured ranges of joint movement . To assess the validity of the examination , a pre-defined algorithm was applied to the nurse 's examination findings in patients from both groups , and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic 's independent diagnosis as the reference st and ard . RESULTS The between observer repeatability of physical signs varied from good to excellent , with κ coefficients of 0.66 to 1.00 for most categorical observations , and mean absolute differences of 1.4 ° –11.9 ° for measurements of shoulder movement . The sensitivity of the schedule in comparison with the reference st and ard varied between diagnoses from 58%–100 % , while the specificities ranged from 84%–100 % . The nurse and the clinic physician generally agreed in their diagnoses , but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis , whereas the clinic physician did not . CONCLUSION The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting . Examination can feasibly be delegated to a trained nurse , and the protocol has the benefit of face and construct validity as well as consensus backing . Its performance in the community , where disease is less clear cut , merits separate evaluation , and further refinement is needed to discriminate between discrete pathologies at the shoulder The histopathologic features from 11 patients who were treated surgically for lateral epicondylitis were grade d and compared to similar tissue from 12 cadaveric spec imens . All studies were done by a single pathologist who had no knowledge of the origin of the specimen . The surgical specimens were interpreted as abnormal in all 11 specimens , and all 12 of the control specimens were reported as being without histologic abnormality . Vascular proliferation was present in 10 of 11 and focal hyaline degeneration was recorded in all 11 of the surgical specimens . Neither feature was present in any of the control material ( P < 0.001 ) . These data suggest that chronic refractory lateral epicondylitis requiring sur gery is a degenerative rather than inflammatory proc ess . This may account for the lack of response to rest and antiinflammatory medication OBJECTIVE The purpose of this article is to evaluate prospect ively the utility of sonographic measurements of the common extensor tendon for diagnosing lateral epicondylitis . SUBJECTS AND METHODS Forty-eight patients with documented lateral epicondylitis and 63 healthy volunteers were enrolled and underwent ultrasound of the elbow joint .  The common extensor tendon overlying the bony l and mark was scanned transversely , and the cross-section area and the maximum thickness were measured . Clinical examination was used as the reference st and ard in the diagnosis of lateral epicondylitis . Data from the patient and control groups were compared with established optimal diagnostic criteria for lateral epicondylitis using receiver operating characteristic curves . Qualitative evaluation with  grayscale ultrasound  was also performed on patients and healthy volunteers . RESULTS The common extensor tendon was significantly thicker in patients with lateral epicondylitis than in control subjects ( p < 0.01 ) . Tendon thickness greater than 4.2 mm ( sensitivity , 78.4 % ; specificity , 95.2 % ; accuracy , 87.7 % ) and area larger than or equal to 32 mm(2 ) ( sensitivity , 86.3 % ; specificity , 82.5 % ; accuracy , 84.2 % ) were highly predictive of lateral epicondylitis . For qualitative evaluation with gray-scale ultrasound , overall sensitivity , specificity , and accuracy values in the diagnosis of lateral epicondylitis were 76.5 % , 76.2 % , and 76.3 % , respectively . CONCLUSION The quantitative sonographic measurements had an excellent diagnostic performance for lateral epicondylitis , as well as good or excellent interreader agreement . A common extensor tendon cross-section area greater than or equal to 32 mm(2 ) and a thickness of 4.2 mm correlated well with the presence of lateral epicondylitis . However , further prospect i ve study is necessary to determine whether quantitative ultrasound with these cutoff values can improve the accuracy of the diagnosis of lateral epicondylitis OBJECTIVE Tennis elbow is a common complaint . Several treatment strategies have been described , but an optimal strategy has not been identified . Sonographic imaging as a predictive factor has never been studied . The aim of our study was to determine the value of sonographic findings in predicting response to conservative therapy for tennis elbow . This was done in a r and omized controlled trial in which the effectiveness of a brace only , physical therapy only , and a combination of both were compared . SUBJECTS AND METHODS Patients with tennis elbow complaints were r and omized .  Sonography was performed before r and omization in 57 patients . Outcome measures at 6 weeks ' follow-up were success rate and decrease in pain ( scale , 0 - 100 ) . Data were analyzed using an intention-to-treat analysis . RESULTS In only 75 % of the imaged patients , sonographic abnormalities were identified and the clinical diagnosis could thus be confirmed . The following entities were identified : hypo- and hyperechogenicity , swelling , calcification , bursitis , enthesopathy , and tendinosis . The positive predictive value of sonography for the different entities varied between 0.78 and 0.82 , and the negative predictive value ranged between 0.23 and 0.71 . Predictive value was studied by subgroups of sonographic findings : hypoechoic , swelling present , enthesopathy , any entity present , and no entity present . We found no significant differences among the subgroups for either success rate ( range , 40 - 54 % ) or mean decrease in pain ( range , 16 - 28 percentage points ) . CONCLUSION No predictive value of sonography for the detection of abnormalities was identified in this study . Its diagnostic capability showed limited value . However , limitations in this study necessitate drawing definitive conclusions with care 
    Output:
    
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 .
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 objective ly 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 design ing an appropriate treatment suited to patient ’s condition