Lateral epicondylitis, commonly known as tennis elbow, is one of the most prevalent overuse injuries affecting the elbow joint. It is characterized by pain and tenderness over the lateral epicondyle of the humerus, which is exacerbated by activities involving gripping or wrist extension. ^[1] The condition is most commonly seen in individuals between 35 and 55 years of age and is frequently associated with repetitive strain injuries, especially in individuals engaged in activities involving repeated wrist extension, supination, and heavy lifting. ^[2]

The pathophysiology of lateral epicondylitis is thought to involve microtears and angiofibroblastic degeneration of the extensor carpi radialis brevis (ECRB) tendon, leading to chronic inflammation and localized pain. ^[3] Historically considered an inflammatory condition, recent evidence supports the theory of tendinosis rather than tendinitis, suggesting degenerative rather than inflammatory changes in the affected tendons. ^[4]

The clinical diagnosis is largely based on a detailed history and physical examination. Patients typically present with lateral elbow pain that worsens with gripping, lifting, or activities requiring wrist extension. ^[5] Pain on palpation of the lateral epicondyle, resisted wrist extension, and pain on passive wrist flexion are hallmark findings. Imaging studies such as ultrasound and MRI can be helpful in chronic or refractory cases but are not routinely required for diagnosis. ^[6]

Various conservative management strategies have been employed to address lateral epicondylitis. These include rest, activity modification, physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), bracing, extracorporeal shockwave therapy, and corticosteroid injections. ^[7] Physical therapy interventions—particularly those focusing on eccentric strengthening exercises, stretching of the forearm extensors, and ultrasound therapy—have shown favorable outcomes in improving pain and function⁶. Taping techniques, such as the use of forearm straps or counterforce braces, are also commonly recommended for symptom relief. ^[8]

The role of corticosteroid injections, although effective in the short term, has been questioned due to concerns about long-term tendon degeneration and recurrence. ^[9] Recent research has emphasized the benefit of a structured rehabilitation program focusing on biomechanical correction and muscle reconditioning to achieve sustained improvement. ^[10]

Despite the availability of multiple treatment modalities, a standard treatment protocol remains elusive, with variability in response among different individuals. Conservative management remains the mainstay of treatment, with surgical intervention reserved for those who do not respond to non-operative measures after six to twelve months. ^[11]

Given the frequency of this condition and its impact on functional capacity, particularly in the working-age population, this study aims to evaluate the clinical presentation and effectiveness of conservative treatment strategies employed in a tertiary care setting. It will provide an evidence-based perspective on commonly used therapeutic approaches, assess their impact on pain and functional outcomes, and offer recommendations for clinical practice. ^[12].

This is a Prospective observational study was conducted in the Department of Physiotherapy at Index Physiotherapy College and hospital. Data will be collected from patients attending the outpatient department (OPD) and those referred for physiotherapy with a confirmed clinical diagnosis of lateral epicondylitis.

The study will be conducted over a period of 24 months, including recruitment, intervention, and follow-up.

Sample Size Calculation

Sample size is calculated based on previous studies that reported improvement in VAS scores with conservative therapy.

Assuming:

• 95% confidence level
• 80% power
• An effect size of 0.5
  Using the formula for comparing two means:

n = (Zα + Zβ)² × 2σ² / Δ²
A minimum sample size of 260 patients (30 in each treatment protocol if comparative subgroups are planned) is considered adequate.

Inclusion Criteria

• Patients aged 18 to 60 years.
• Clinically diagnosed with lateral epicondylitis (based on Cozen’s, Mill’s, or Maudsley’s tests).
• Symptom duration of at least 2 weeks.
• Willing to participate and provide informed consent.

 Exclusion Criteria

• History of trauma or fracture to the affected elbow.
• Previous elbow surgery or steroid injections in the past 3 months.
• Inflammatory joint diseases (e.g., rheumatoid arthritis).
• Cervical radiculopathy or other neuropathies mimicking lateral epicondylitis.
• Pregnancy or systemic corticosteroid use.

Methodology

Enrollment: Patients fulfilling inclusion criteria will be recruited after obtaining written informed consent.

Baseline Assessment: Demographic data, Duration and severity of symptoms, Clinical tests (Cozen’s, Mill’s, Maudsley’s), Baseline VAS score (0–10) and Grip strength using hand dynamometer

Follow-Up and Outcome Measures: Weekly reassessment of VAS and PRTEE scores. Final grip strength measurement at 6 weeks.

Statistical Analysis

Data was entered in Microsoft Excel and analyzed using SPSS v25.0. Descriptive statistics: Mean, standard deviation for continuous variables; frequencies for categorical data. Inferential statistics: Paired t-test to compare pre- and post-treatment scores. Chi-square test for categorical outcomes. p-value < 0.05 considered statistically significant. Subgroup analysis may be done based on age group, symptom duration, or initial severity.

Table 1: Baseline Demographic Characteristics of Participants

The study included a total of 260 patients diagnosed with lateral epicondylitis. The mean age of participants was 42.3 years, with a fairly balanced gender distribution (53.8% male, 46.2% female). The majority of patients (65.4%) had involvement of their dominant hand, and the average symptom duration was 6.2 weeks. Clinical tests revealed a high positivity rate for Cozen’s (92.3%), Mill’s (86.5%), and Maudsley’s (80.8%) tests, confirming the clinical diagnosis. Baseline pain (VAS: 6.8 ± 1.1) and functional disability (PRTEE: 62.4 ± 8.7) were considerably high, while grip strength was reduced (18.3 ± 4.5 kg).

Table 2: Baseline Clinical Assessment

A significant and consistent reduction in pain levels was observed over the 6-week conservative treatment period. The VAS score decreased from 6.8 at baseline to 0.8 at week 6, indicating excellent pain relief with the physiotherapy protocol. Weekly improvements were steady, particularly in the first 3 weeks.

Table 3: Weekly VAS Score Reduction

There was a notable reduction in PRTEE scores from 62.4 at baseline to 14.9 by week 6. This reflects significant improvement in both pain and functional aspects of the condition, as measured by a condition-specific questionnaire.

Table 4: Grip Strength Improvement (Pre vs Post Intervention)

Symptom Duration: Patients with symptoms ≥4 weeks showed slightly higher pain relief and functional gains than those with <4 weeks duration, though the difference was not statistically significant.

Age Groups: All age groups showed improvement, with the 18–30 age group demonstrating the highest VAS and PRTEE reductions. However, treatment was effective across all age brackets.

Table 5: Subgroup Analysis by Age Group

VAS (Pain Reduction): Greatest in the 18–30 group (mean reduction of 6.2 units). Slightly lower in the 46–60 group (mean 5.8), suggesting pain relief was marginally less pronounced with increasing age.

ΔPRTEE (Functional Gain): Younger participants also demonstrated greater functional recovery (ΔPRTEE of 48.7 in 18–30 vs. 46.1 in 46–60), although the differences are modest.

Statistical Significance: The p-values for the 18–30 group are 0.06 for VAS and 0.09 for PRTEE. These approach, but do not reach, conventional statistical significance (p < 0.05). This suggests a trend toward better improvement in younger patients, though not conclusively proven due to lack of statistical significance.

In this study, the study included a total of 260 patients diagnosed with lateral epicondylitis. The mean age of participants was 42.3 years, with a fairly balanced gender distribution (53.8% male, 46.2% female). The majority of patients (65.4%) had involvement of their dominant hand, and the average symptom duration was 6.2 weeks. Clinical tests revealed a high positivity rate for Cozen’s (92.3%), Mill’s (86.5%), and Maudsley’s (80.8%) tests, confirming the clinical diagnosis. Baseline pain (VAS: 6.8 ± 1.1) and functional disability (PRTEE: 62.4 ± 8.7) were considerably high, while grip strength was reduced (18.3 ± 4.5 kg).

The average participant age in our study reflects the peak incidence in the 35–55 age group, commonly reported in population-based studies such as Shiri et al. (2006). ^[102] This age group typically experiences cumulative tendon microtrauma due to occupational and recreational overuse, especially involving wrist extension and gripping. Aging tendons are more prone to degenerative changes due to reduced tenocyte activity, vascularity, and collagen crosslinking, predisposing them to tendinopathy with repetitive stress. ^[13]

The mean symptom duration of 6.2 weeks suggests that most patients were in the subacute phase of the condition. Previous work by Bisset et al. and Smidt et al. emphasized that conservative treatment tends to be most effective when initiated early, before chronic degenerative changes dominate. ^[14] Delayed presentation has been associated with central sensitization, tendon fibrosis, and poorer response to therapy, underscoring the importance of timely diagnosis and intervention. ^[15]

Despite the delayed onset in some patients, our study showed uniform improvement across symptom durations, indicating that the pathological changes remained reversible, at least within the 2–12-week window.

Mean VAS score of 6.8 ± 1.1 confirms that participants presented with moderate-to-severe pain, typical of active-phase lateral epicondylitis. This is comparable to studies by Smidt et al. and Struijs et al., which reported baseline VAS scores between 6.5 and 7.0 in treatment-seeking populations. ^[16]

The average grip strength of 18.3 ± 4.5 kg at baseline reflects a substantial reduction when compared to age- and sex-matched healthy controls, where average values typically exceed 30 kg. This deficit is attributed to pain inhibition, mechanical inefficiency due to tendon damage, and neuromuscular adaptations such as motor unit recruitment changes. ^[17] The role of the ECRB tendon, central to grip force stabilization during wrist extension, is critical. Studies by Werner et al. demonstrated that patients with lateral epicondylitis have significantly reduced EMG activity and delayed muscle recruitment patterns in the ECRB, explaining diminished grip performance. ^[18]

The combination of high test positivity, elevated pain, impaired function, and reduced grip strength points to an integrated pathophysiological model: Tendinosis at the ECRB origin leads to reduced load tolerance and provoked pain on mechanical stress (confirmed by Cozen’s and Mill’s tests). Chronic overuse causes collagen disorganization, microtearing, and neovascularization, which are the hallmarks of lateral epicondylitis. Neural mechanisms such as central sensitization and altered cortical representation of the affected limb also contribute to increased pain perception and motor control dysfunction. ^[19]

Pain reduction, as evidenced by the reduction in Visual Analogue Scale (VAS) scores from 6.8 to 0.8, aligns with prior studies by Smidt et al. and Bisset et al., who reported significant short-term and medium-term relief with structured physiotherapy and bracing. The eccentric strengthening exercises used in this study likely contributed to tendon remodeling and mechanical desensitization. Eccentric loading has been shown to induce collagen realignment and stimulate tenocyte activity, aiding in tendon regeneration. ^[20].

The results validate the use of a structured conservative approach in managing lateral epicondylitis. The improvements across all clinical domains, high safety profile, and alignment with established tendon healing mechanisms underscore its continued relevance in orthopedic practice

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