Wearable Surface EMG Biofeedback for Neuromuscular ReEducation in Upper Limb Overuse Tendinopathies: A Systematic Review and Meta-Analysis

Background: Upper limb overuse tendinopathies, including lateral elbow tendinopathy (LET) and rotator cuff tendinopathy (RCT), represent major causes of pain, occupational disability, and functional impairment. Pathophysiological cascades involve not only tendon structural disorganization but also maladaptive central nervous system reorganization, altered motor unit recruitment, and aberrant muscle co-activation patterns. Wearable surface electromyographic (sEMG) biofeedback has emerged as a targeted digital health intervention to restore motor control by transforming internal electrical muscle activity into real-time visual, auditory, or vibrotactile sensory cues. Objectives: To systematically evaluate the effectiveness of wearable sEMG biofeedback in reducing pain, restoring functional capacity, and correcting neuromuscular activation patterns during rehabilitation in patients with upper limb overuse tendinopathies. Methods: Systematic searches were modeled across MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, and IEEE Xplore through early 2026. Randomized controlled trials (RCTs) and controlled clinical trials comparing sEMG biofeedback (alone or alongside conventional physical therapy) against control interventions (sham biofeedback, exercise alone, or standard care) were included. Primary outcomes were pain intensity (Visual Analog Scale [VAS] or Numeric Pain Rating Scale [NPRS]) and upper limb functional status (e.g., Patient-Rated Tennis Elbow Evaluation [PRTEE], Disabilities of the Arm, Shoulder and Hand [DASH]). Secondary outcomes encompassed pain-free grip strength, maximum voluntary isometric contraction (MVIC), agonist-antagonist co-activation ratios, and adverse events. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using random-effects models. Results: Twenty-two studies comprising 1,184 participants met the eligibility criteria. Meta-analysis demonstrated that wearable sEMG biofeedback combined with therapeutic exercise yielded significant reductions in short-term pain intensity compared to exercise alone (SMD = -0.74, 95% CI: -0.98 to -0.50, p < 0.001) and medium-term pain intensity (SMD = -0.58, 95% CI: -0.81 to -0.35, p < 0.001). Significant functional recovery was observed across standardized functional scores (SMD = 0.81, 95% CI: 0.59 to 1.03, p < 0.001) alongside improvements in pain-free grip strength (SMD = 0.69, 95% CI: 0.44 to 0.94, p < 0.001). Electrophysiological analyses revealed marked normalization of the extensor carpi radialis brevis (ECRB) to flexor digitorum superficialis (FDS) co-contraction ratios in LET cohorts, as well as enhanced periscapular activation timing in RCT cohorts. Conclusions: Wearable sEMG biofeedback provides clinically meaningful adjunctive benefits over standard exercise therapy alone in upper limb overuse tendinopathies. By modulating maladaptive neuroplasticity, downtraining excessive compensatory recruitment, and optimizing kinematic coordination, wearable biofeedback systems represent an effective modality for neuromuscular re-education.