Full Length Article| Volume 35, ISSUE 4, P541-551, October 2022

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Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) – A systematic review

Published:February 27, 2021DOI:


      • Cozen's test and grip strength difference between elbow flexion and extension provide high accuracy for the diagnosis of lateral elbow tendinopathy (LET).
      • Substantial heterogeneity in inclusion criteria, type of equipment, examiner/operator, mode of application and reference standards limit the internal and external validity of the results in diagnostic studies of LET.
      • Sonoelastography, Grayscale Doppler Ultrasound Imaging and MRI provide variable diagnostic accuracy range depending on the entities reported and should be cautiously considered in LET if differential diagnosis is indicated.



      Reviews on the diagnostic performance of the examination tests for lateral elbow tendinopathy (LET) based on updated context-specific tools and guidelines are missing.


      To review the diagnostic accuracy of examination tests used in LET.


      Systematic review following PRISMA-DTA guidelines.


      We searched MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, and Cochrane Library databases. The QUADAS-2 checklist was used to assess the methodological quality of the eligible studies. We included diagnostic studies reporting the accuracy of physical examination tests or imaging modalities used in patients with LET.


      Twenty-four studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies). Most studies (97%) were assessed with “unclear” or “high risk” of bias. Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%). Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%). MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%). The Cozen's test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%).


      Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated. USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment and reference standards across the studies.

      Systematic review registration

      PROSPERO ID CRD42020160402


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      JHT Read for Credit

      Quiz: # 917

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • # 1.
        The study design is
        • a.
        • b.
          systematic review
        • c.
          prospective cohort
        • d.
          case series
      • # 2.
        Diagnostic performance of _____________ was investigated
        • a.
        • b.
        • c.
          physical examination
        • d.
          all of the above
      • # 3.
        LET is seen
        • a.
          more frequently in the UK than in the US
        • b.
          in women more frequently than in men
        • c.
          in men as frequently as in women
        • d.
          in men more frequently than in women
      • # 4.
        Both ___________ and ___________ were calculated for each Dx tool
        • a.
          ease of use and cost
        • b.
          specificity and sensitivity
        • c.
          selectivity and specificity
        • d.
          reliability and validity
      • # 5.
        Cozen's Test and grip strength were highly inaccurate tools in diagnosing LET
        • a.
          not true
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.