Lateral Epicondylalgia as a Nociceptive/Nociplastic Pain Condition According to the International Association for the Study of Pain (IASP) Taxonomy: A Theoretical Hypothesis

Lateral epicondylalgia (LE) is a chronic musculoskeletal pain condition characterized by treatment effect heterogeneity. The identification of specific pain phenotypes may help in subgrouping LE patients based on their predominant pain mechanism, thereby supporting the development of more targeted treatments. In the current proposal, we present a conceptual application of the International Association for the Study of Pain (IASP) taxonomy to identify a predominant LE pain phenotype. The clinical presentation of LE is traditionally considered predominantly nociceptive, with the wrist extensor tendon as the main peripheral driver. Thus, the presence of trigger point (TrP)-associated referred pain has also been considered as a potential peripheral nociceptive drive. However, the treatment of peripheral drivers alone has shown limited short-term effects in LE, requiring research beyond possible peripheral inputs. Furthermore, evidence supports the presence of altered pain processing in some individuals with LE, suggestive of nociplastic pain features in a subgroup of patients. The potential presence of nociplastic features would imply the need to address maladaptive neuroplasticity associated with pain processing in these patients with LE. The current proposal hypothesizes that LE is a heterogeneous pain condition in which different pain phenotypes, e.g., nociceptive-alone, nociplastic, or mixed-type, can coexist in some patients with different relevance according to the duration, intensity, stage and severity of the disease. Recognizing the relative predominance of nociceptive and nociplastic phenotypes may guide more individualized treatment selection in individuals with LE. However, these hypotheses require prospective validation before they can be established as a clinical decision-making tool. Future studies should identify high-value care options for the treatment of people with LE, as current approaches only yield short-term effects.