Tennis Elbow Diagnosis

Tennis Elbow Diagnosis

Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) – A systematic review. Journal of Hand Therapy (2021)
Stefanos Karanasios, Vasileios Korakakis, Maria Moutzouri, Eleni Drakonaki, Klaudia Koci, Vasiliki Pantazopoulou, Elias Tsepis, Georgios Gioftsos

This study was a systematic review of 1604 publications. The total number of participants was 1370 (2086 elbows), the sample size ranged from 8 to 224 participants (8 to 408 elbows) with a mean age 44.3 years.

Lateral elbow tendinopathy (LET) is the most common cause of pain in the elbow due to tendinopathy of the common extensor tendon at the lateral epicondyle.

Presents equally in men and women, 1% to 3% of the population will experience LET at the age range of 35 to 50 years.

The clinical diagnosis of LET is traditionally based on:

  • the presence of pain in the lateral aspect of the elbow radiating to the forearm
  • tenderness of the lateral epicondyle
  • positive response to gross provocation tests, namely the Cozen‘s, Mills, or Maudsley‘s tests


[one_third]Cozen’s test
Cozen’s test [/one_third][one_third]Mill’s test
Mill’s test[/one_third][one_third]Maudsley test
Maudsley test

Most clinical tests are based on provocation of symptoms, while imaging aims to identify degenerative tissue changes or abnormalities. However, the relationship between structural tissue disorganization and symptoms is limited as tendinopathy symptoms are independent of the presence and the extent of pathology within the tendon.

  • Diagnostic ultrasound imaging (USI) is proposed as an accurate and cost-effective method for examining the common extensor tendon (CET) of the elbow, with several advantages over magnetic resonance imaging (MRI).
  • More recently, the use of Doppler imaging and USI elastography has been argued to improve the validity of USI in tendinopathy, allowing the assessment of neovascularity and tissue stiffness, respectively.

This review aimed to evaluate the diagnostic accuracy of physical examination tests and imaging for patients with LET, and inform clinical practice based on published guidelines, rigorous risk of bias assessment criteria, and a transparent approach for the quality of evidence.

Twenty-four studies with 1370 participants were analysed to evaluate the diagnostic accuracy of medical imaging and physical examination tests in LET.

USI was the most prevalent index test presenting diverse and variable diagnostic accuracy with a wide spectrum of abnormal musculoskeletal findings reported.

Need to consider that MRI is good to diagnose tendon thickening, tear of enthesopathy – but it is costly and a significant proportion of asymptomatic individuals presents structural tendon abnormalities in the upper and the lower limb.

The use of USI and MRI in the diagnosis of LET provides variable diagnostic accuracy values depending on the tissue abnormalities reported. The generalizability of the findings is limited due to the substantial heterogeneity found in inclusion criteria, operator skills, experience, mode of application, and equipment characteristics. Based on limited evidence, the Cozen‘s test and a decrease in grip strength between elbow flexion present high sensitivity values.

In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension (J Hand Surgery 2007; 32A: 882-886)

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