Psychosocial and personality factors and physical measures in lateral epicondylalgia reveal two groups of “tennis elbow” patients, requiring different management

Abstract Background and purpose Nirschl's lateral epicondylalgia (LE) classification appears prognostic but is based upon an outdated model of tendinopathy. Psychosocial factors which may negatively influence treatment outcomes, central nervous system mediated hypersensitivity and motor impairment all occur in epicondylalgia. This study examines psychosocial/personality factors and physical measures in LE correlating them with Nirschl's sub-groups. Methods Fifty-four subjects with LE and 43 healthy controls, recruited from primary care in Norway were assessed. Measures included: pressure pain threshold (PPT), isometric maximal load pain tolerance (MLT) and isometric low load (sustained hold of 0.5kg weight) pain tolerance (LLT) of the wrist extensors, all of which were undertaken bilaterally; the Orebro Musculoskeletal Pain Questionnaire (OMPSQ), and the Swedish Scales of Personality. Results Patients had significantly lower pain thresholds than controls especially at the common extensor origin, but thresholds did not differentiate Nirschl's groups. MLT did not differentiate between controls and patients or between pain groups. LLT differentiated pain patients from controls but not between different pain groups. The OMPSQ score was significantly different between three out of four of Nirschl's pain groups and both pain thresholds and MLT in both the painful and non-/less painful arms were significantly but negatively correlated with the OMPSQ score. Somatic anxiety was significantly different between healthy controls and Nirschl's most symptomatic pain group; and also correlated with the OMPSQ score. Conclusions The OMPSQ differentiated Nirschl's sub-groups more effectively than the PPT, MLT or LLT, but the control group did not complete the OMPSQ, so a comparison of the subjects with LE to symptom-free subjects was not possible. Elevated somatic anxiety in the most symptomatic patients may indicate possible alexithymia or an inability to understand or cope with somatic symptoms of distress. The subjects in this study with epicondylalgia exhibited widespread, likely central nervous system mediated hypersensitivity, motor impairment and psychosocial factors in keeping with a modern model of LE. This hypersensitivity suggests epicondylalgia should not be considered a localised pathology and management should be tailored towards underlying multidimensional biopsychosocial pain mechanisms. Possible pain mechanisms driving this hypersensitivity are postulated. LLT, a novel impairment test, is significantly reduced in LE and should be examined in this patient group, and possibly rehabilitated specifically. Based upon physical and psychological data from this study, Nirschl's sub-grouping seems too detailed and our results suggest that the four groups should be reduced to two. Thus, for diagnostic purposes the Nirschl's groups I and II could be collapsed to one group, and groups III and IV to a second group. Implications Psychosocial and personality factors should be measured in subjects with epicondylalgia as they correlate with physical signs. Management should therefore be tailored to patient presentations, particularly where significant psychosocial factors or specific motor impairments exist.