Advances in the Diagnosis, Management, and Rehabilitation of Lateral Epicondylitis: A Comprehensive Review of Recent Evidence

Lateral epicondylitis, commonly known as “tennis elbow,” is a prevalent musculoskeletal disorder characterized by pain and tenderness over the lateral aspect of the elbow. It typically results from repetitive overuse of the forearm extensors, particularly the extensor carpi radialis brevis (ECRB) tendon [1]. Despite its colloquial name, the majority of those affected are not athletes but individuals engaged in repetitive manual labor or activities involving gripping and wrist extension [2].

Historically, the condition was first described as “writer’s cramp” by Runge in 1873. This term has evolved over time, reflecting a shift in understanding from an inflammatory process to a degenerative one [3]. Modern terminology emphasizes the degenerative nature of lateral epicondylitis, involving microtears and angiofibroblastic degeneration in the ECRB tendon rather than inflammation [4].

Epidemiological data suggest that lateral epicondylitis affects approximately 1–3% of the general population annually, peaking in individuals aged 30 to 50 [5]. While some cases resolve spontaneously, chronic forms of the condition can significantly impair quality of life and functional capacity.

The clinical diagnosis of lateral epicondylitis relies primarily on patient history and physical examination, including provocative tests such as Cozen’s and Mill’s tests. Although imaging is not routinely required, ultrasound and MRI are useful in complex or refractory cases [6]. In addition, patient education and accessible resources play a crucial role in promoting treatment adherence. However, studies indicate that current patient education materials often vary in readability and quality, which can hinder patient engagement [7].

Treatment strategies for lateral epicondylitis include conservative and surgical approaches. Conservative treatments encompass activity modification, physiotherapy, bracing, and pharmacological options such as NSAIDs. More recently, modalities such as extracorporeal shock wave therapy (ESWT) and platelet-rich plasma (PRP) injections have been explored for their regenerative potential [8]. Despite these advances, uncertainties remain regarding long-term treatment effectiveness, reinforcing the need for evidence-based guidelines [4].

This review fills a critical research gap by providing an up-to-date synthesis of the latest evidence (2019–2024) on the etiology, diagnosis, management, and emerging treatments for lateral epicondylitis. By focusing on recent systematic reviews and meta-analyses, this paper aims to clarify inconsistencies in diagnostic terminology, highlight the most effective conservative treatments, and explore the role of adjunctive therapies. Ultimately, it seeks to inform clinicians and researchers of current best practices and outline directions for future research.

This review was conducted to provide a comprehensive synthesis of the recent literature on the diagnosis, pathophysiology, and management of lateral epicondylitis (tennis elbow). A structured literature search was performed to identify peer-reviewed articles published in the last five years (from January 2019 to March 2024), ensuring the inclusion of the most current evidence and clinical practices.

Search Strategy

Electronic databases including PubMed, Scopus, ScienceDirect, and Google Scholar were systematically searched using a combination of the following keywords and Boolean operators: “lateral epicondylitis,” “tennis elbow,” “management,” “treatment,” “rehabilitation,” “physiotherapy,” “extracorporeal shock wave therapy,” “PRP,” “corticosteroid injection,” and “surgical treatment.” Filters were applied to limit the results to English-language publications and articles published within the last five years.

Inclusion and Exclusion Criteria

Articles were included in this review if they:

• Were published between 2019 and 2024
• Focused on the diagnosis, treatment, or management of lateral epicondylitis
• Were systematic reviews, meta-analyses, randomized controlled trials (RCTs), clinical trials, or expert reviews
• Provided original or synthesized data relevant to clinical decision-making
• Studies were excluded if they
• Focused on conditions unrelated to lateral epicondylitis
• Were case reports, editorials, or conference abstracts
• Were published in a language other than English
• Had inaccessible full texts

Figure 1: PRISMA Flowchart of the Search Strategy

Study Selection

The initial search identified 204 articles. After removing 58 duplicates, 146 unique studies were screened based on titles and abstracts for relevance. Full texts of 32 articles were then reviewed in detail to confirm eligibility. Finally, 6 studies met the inclusion criteria and were included in this review (see PRISMA flowchart in Figure 1). One excluded study focused on artificial intelligence prediction models and did not directly examine clinical treatments or diagnostic criteria.

Data Extraction and Synthesis

Key data from the selected studies were extracted and summarized. These included study design, population characteristics, type of intervention, outcome measures, and main findings. A narrative synthesis approach was employed to organize the findings thematically into diagnostic evaluation, conservative treatment strategies, interventional techniques, surgical management, and outcomes. The methodological quality and relevance of the studies were also considered during interpretation.

A total of six studies, published between 2020 and 2023, met the inclusion criteria and were analyzed in this review. These studies addressed diverse aspects of the management and diagnosis of lateral epicondylitis, including physiotherapy interventions, ergonomic adaptations, conservative and surgical treatments, and the variability of diagnostic criteria. No formal quality appraisal tool was applied, given the narrative synthesis approach and the limited number of included studies. Nonetheless, all studies were evaluated for methodological rigor and clinical relevance.

Table 1: Characteristics of the Included Studies

The thematic synthesis of these studies revealed several recurring themes, summarized in Table 2.

Across the studies, eccentric strengthening emerged as the most effective conservative intervention, with Chen and Baker [9] and Landesa-Piñeiro and Leirós-Rodríguez [6] reporting up to 42% improvement in pain and 35% in function. Ergonomic adaptations and patient education were identified by Stegink-Jansen et al. [10] and Chen et al. [11] as critical for preventing recurrence and supporting long-term recovery.

Variability in diagnostic terminology was highlighted by Di Filippo et al. [12], who observed inconsistent usage of terms such as “lateral epicondylitis,” “lateral epicondylalgia,” and “lateral elbow tendinopathy,” along with variable application of provocative tests (e.g., Cozen’s, Mill’s). This inconsistency complicates direct comparison of findings across studies and reinforces the need for standardized diagnostic criteria.

Conservative management remains the first-line approach for most patients, as emphasized by Karabinov and Georgiev [3]. Surgery, including debridement techniques, is generally reserved for those with refractory symptoms not responding to prolonged conservative care. Adjunctive therapies such as extracorporeal shock wave therapy and platelet-rich plasma injections offer moderate short-term benefits, but the consensus across studies supports their use as complementary rather than primary interventions.

Table 2: Extracted Themes from the Included Studies and Corresponding References

The present review synthesizes recent evidence (2020–2023) on the diagnosis and management of lateral epicondylitis, highlighting that eccentric strengthening exercises, in combination with ergonomic interventions and patient education, remain the cornerstone of conservative treatment. Chen and Baker [9] and Landesa-Piñeiro and Leirós-Rodríguez [6] demonstrated that eccentric exercise reduces pain by up to 42% and improves function by up to 35%. This finding is consistent with earlier literature from the 2000s [13] that first emphasized the benefits of eccentric loading protocols in promoting tendon healing. However, our review also reveals that these interventions have now become standard practice rather than emerging strategies.

Ergonomic adaptations, as identified by Stegink-Jansen et al. [10] and Chen et al. [11], are another critical element of contemporary management. These findings support previous research [14] suggesting that modifying occupational and daily activity risk factors can reduce the risk of recurrence and support sustained recovery.

An important contribution of this review is the acknowledgment of persistent heterogeneity in diagnostic terminology and criteria. Di Filippo et al. [12] reported the interchangeable use of terms like “lateral epicondylitis” and “lateral epicondylalgia,” reflecting a longstanding issue identified in older reviews [15]. This lack of standardization complicates direct comparison of studies and may contribute to variability in treatment effectiveness reported across research.

Our review underscores that conservative care remains the primary treatment approach, with surgical intervention reserved for persistent cases—a view that aligns with earlier comprehensive reviews [16]. Adjunctive therapies such as extracorporeal shock wave therapy and platelet-rich plasma injections appear promising in the short term [8], though their role should be considered complementary. These findings suggest a continuity in best-practice recommendations, with newer evidence further validating long-standing principles of management.

Critical Appraisal and Limitations

A notable limitation of the included studies is the absence of uniform diagnostic criteria, which introduces heterogeneity and may limit the generalizability of findings. Additionally, the studies varied in methodology and outcome measures, from systematic reviews to narrative reviews, making direct quantitative comparisons challenging. The lack of high-quality randomized controlled trials in some of the included literature further limits the strength of the conclusions drawn.

Another limitation of this review itself is the relatively small number of included studies (six), reflecting the challenges of conducting robust research in this area. While this highlights the need for future high-quality trials, it also underscores the importance of cautious interpretation and individualized clinical application.

To sum up, while significant advances have been made in refining conservative and adjunctive treatments for lateral epicondylitis, persistent gaps remain in standardizing diagnostic frameworks and establishing long-term efficacy of newer therapies. Future research should prioritize harmonizing diagnostic criteria and conducting well-designed randomized controlled trials to strengthen the evidence base and further improve patient outcomes.

In summary, this review reinforces the effectiveness of a multimodal, patient-centered approach for the management of lateral epicondylitis. Eccentric strengthening exercises, ergonomic modifications, and patient education should be prioritized as the foundation of conservative therapy. Adjunctive therapies such as extracorporeal shock wave therapy and platelet-rich plasma injections offer promising short-term benefits and can be considered as complementary options in individualized treatment plans. For clinical practice, it is recommended that healthcare providers adopt standardized diagnostic frameworks—such as incorporating consistent use of Cozen’s and Mill’s tests and clear criteria for imaging referrals—to improve early diagnosis and treatment consistency. Integrating ergonomic assessments into routine evaluations and providing tailored activity modification strategies should also be standard practice to enhance patient engagement and reduce recurrence.

Future research should focus on developing consensus-based diagnostic criteria to address the variability highlighted in this review. Additionally, high-quality randomized controlled trials are needed to compare the long-term effectiveness of emerging adjunctive therapies, such as ESWT and PRP, against standard conservative care. Investigating the role of multimodal interventions in different patient subgroups—such as manual laborers versus athletes—and exploring the cost-effectiveness of these strategies would also provide valuable guidance for optimizing treatment pathways.

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