Evidence of Bilateral Localized, but Not Widespread, Pressure Pain Hypersensitivity in Patients With Upper Extremity Tendinopathy/Overuse Injury: A Systematic Review and Meta-Analysis.

Abstract

The presence of altered nociceptive pain processing in patients with upper extremity tendinopathy/overuse injury is conflicting. Our aim was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas between patients with upper extremity tendinopathy/overuse injury and controls. Five databases were searched from inception to October 15, 2020. The authors selected case-control studies comparing PPTs between individuals with upper extremity tendinopathy/overuse injury and pain-free controls. Data were extracted for population, diagnosis, sample size, outcome, and type of algometer. Results were extracted by 3 reviewers. The methodological quality/risk of bias (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development and Evaluation approach) were assessed. Meta-analyses of symptomatic, segment-related, and distant pain-free areas were compared. The search identified 807 publications with 19 studies (6 shoulder, 13 elbow) eligible for inclusion. The methodological quality ranged from fair (48%) to good (37%). Patients exhibited lower bilateral PPTs than controls at the symptomatic area (affected side: MD = -175.89 kPa [95% CI = -220.30 to -131.48 kPa]; nonaffected side: MD = -104.50 kPa [95% CI = -142.72 to -66.28 kPa]) and the segment-related area (affected side: MD = -150.63 kPa [95% CI = -212.05 to -89.21 kPa]; nonaffected side: MD = -170.34 kPa [95% CI = - 248.43 to -92.25]) than controls. No significant differences in PPTs over distant pain-free areas were observed. Low to moderate quality evidence suggests bilateral hypersensitivity to pressure pain at the symptomatic and contralateral/mirror areas in patients with upper extremity tendinopathies/overuse injury. Moderate quality of evidence supports bilateral pressure pain sensitivity in the segment-related area (neck) in lateral epicondylalgia, but not in subacromial impingement syndrome. No evidence of widespread pressure pain hyperalgesia was reported. Early identification of people with altered pain modulation could guide clinicians in treatment strategies. This review shows that there is a complex interplay between peripheral and central pain mechanisms in upper extremity tendinopathies/overuse injuries and that there likely are different subgroups of patients with upper extremity conditions.