Dirsek Ağrısına Algoritmik Yaklaşım
Özet
Bu çalışma, dirsek ağrısına klinik pratikte sistematik ve rasyonel bir yaklaşım sunmayı amaçlamaktadır. Dirsek, tek kapsül içinde üç ayrı eklem kompleksinden oluşan ve ligamentöz, tendinöz ve nörovasküler yapılar açısından zengin bir anatomik bölgedir. Bu nedenle dirsek ağrısı farklı patolojilerle ve örtüşen semptomlarla ortaya çıkabilir
. Değerlendirme; ayrıntılı anamnez, kırmızı bayrakların dışlanması ve ağrının anatomik lokalizasyonuna göre sınıflandırılması ile başlar. Lateral, medial, posterior ve anterior bölge temelli yaklaşım ayırıcı tanıyı kolaylaştırır. Provokatif testler klinik şüpheyi desteklerken, direkt grafi, ultrasonografi, MR ve EMG gibi görüntüleme yöntemleri tanıyı netleştirir. Tedavi basamaklıdır: öncelikle konservatif yöntemler (egzersiz, aktivite modifikasyonu, ortez, fizik tedavi modaliteleri) uygulanır. Dirençli olgularda girişimsel tedaviler (PRP, proloterapi, sinir hidrodiseksiyonu, ESWT) değerlendirilebilir. Uzun süreli başarısızlık veya belirgin instabilite ya da nörolojik defisit varlığında cerrahi seçenekler gündeme gelir. Algoritmik yaklaşım, gereksiz tetkik ve müdahaleleri azaltarak doğru ve zamanında tedavi planlamasına katkı sağlar.
This review presents a structured and algorithmic approach to elbow pain in clinical practice. The elbow is a complex anatomical region composed of three joint articulations within a single capsule, supported by ligamentous, tendinous, and neural structures. Consequently, elbow pain may arise from diverse pathologies with overlapping clinical features. Evaluation begins with detailed history taking and exclusion of red flags, followed by localization of pain into lateral, medial, posterior, or anterior compartments to facilitate differential diagnosis. Provocative tests enhance diagnostic accuracy, while imaging modalities such as plain radiography, ultrasonography, MRI, and electromyography help confirm the diagnosis. Management follows a stepwise strategy. Conservative treatment—including exercise therapy, activity modification, orthoses, and physical therapy modalities—is first-line. In refractory cases, interventional options such as platelet-rich plasma injections, prolotherapy, nerve hydrodissection, or extracorporeal shock wave therapy may be considered. Surgical intervention is reserved for persistent symptoms, significant instability, or progressive neurological deficits. An algorithmic framework reduces unnecessary investigations and supports timely, evidence-based clinical decision-making.
Referanslar
Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: One size does not fit all. J Orthop Sports Phys Ther. 2015;45(11):938–949.
Stasinopoulos D, Johnson MI. Lateral elbow tendinopathy: Evidence of pathophysiology and rationale for management. BMJ. 2021;372:n567.
Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015;61(4):174–181.
Journal of Orthopaedic & Sports Physical Therapy (JOSPT). Clinical Practice Guideline: Lateral Elbow Pain. J Orthop Sports Phys Ther. 2022;52(4):CPG1–CPG32.
Struijs PA, Damen PJ, Bakker EW, et al. Conservative treatment of lateral epicondylitis: Brace versus physical therapy or combination of both. Am J Sports Med. 2004;32(2):462–469.
Mishra A, Skrepnik NV, Edwards S, et al. Platelet-rich plasma for chronic tennis elbow: A double-blind, multicenter, prospective clinical trial. Am J Sports Med. 2014;42(2):463–471.
Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Corticosteroid injection, physiotherapy or wait-and-see for lateral epicondylitis: Randomised controlled trial. BMJ. 2015;349:g7708.
Rabago D, Nourani B. Prolotherapy for osteoarthritis and tendinopathy: A systematic review. Clin Med Insights Arthritis Musculoskelet Disord. 2017;10:1179544117714661.
Rompe JD, Hope C, Küllmer K, et al. Low-energy extracorporeal shock wave therapy for chronic lateral epicondylitis. J Bone Joint Surg Am. 1996;78(3):416–424.
Krey D, Borchers J, McCamey K. Examination, diagnosis, and treatment of chronic lateral epicondylitis. Phys Sportsmed. 2015;43(3):305–313.
Cutts S. Cubital tunnel syndrome. Postgrad Med J. 2007;83(975):28–31.
Gervasio O, Zaccone C, Branca D. Radial tunnel syndrome: Long-term results of surgical treatment. J Hand Surg Br. 2008;33(2):218–220.
Camp CL, Dines JS, Dines DM, et al. Ulnar collateral ligament reconstruction in throwing athletes: A systematic review. Am J Sports Med. 2017;45(3):729–736.
Bernstein J, et al. Ulnar collateral ligament injury: Diagnosis and treatment. J Am Acad Orthop Surg. 2019;27(20):e902–e910.
Safran MR, Graham SM. Distal biceps tendon ruptures: Incidence, mechanism, and outcomes. Clin Orthop Relat Res. 2002;404:275–283.
Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: A systematic review. Am J Sports Med. 2008;36(8):1618–1624.
Baumbach SF, Ploeger MM, Kroonen LT. Olecranon bursitis—An evidence-based review. Orthop Clin North Am. 2014;45(2):145–157.
O’Driscoll SW, Morrey BF. Posterior elbow impingement. Clin Sports Med. 1995;14(1):115–125.
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Philadelphia: Elsevier; 2018.
Chang EY, Chung CB, et al. MRI of the elbow: Update on ligaments, tendons, nerves, and cartilage. Radiographics. 2014;34(3):673–687.
Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol. 2008;119(9):1951–1965.
Smidt N, Ashworth NL, van der Windt DA, et al. Corticosteroid injections, physiotherapy, or wait-and-see for tennis elbow: Systematic review. Cochrane Database Syst Rev. 2002;(1):CD003528.
Ahmad CS, Grantham WJ, Greiwe RM. Valgus instability of the elbow. J Am Acad Orthop Surg. 2009;17(4):247–258.
Ciccotti MG, Pollack KM, Ciccotti MC, et al. Elbow injuries in throwing athletes: Comprehensive review. Am J Sports Med. 2017;45(1):119–130.
Stull JD, Nicholson BT, et al. MR imaging of nerve entrapment in the elbow. Magn Reson Imaging Clin N Am. 2015;23(1):129–150.
Walker-Bone K, Palmer KT, Reading I, et al. Prevalence and impact of elbow disorders in primary care. Ann Rheum Dis. 2004;63(8):857–872.
Shiri R, Viikari-Juntura E. Lateral & medial epicondylitis: Systematic review & meta-analysis. Am J Epidemiol. 2011;173(3):276–286.
King GJ, Richards RR, Zuckerman JD. Soft tissue disorders of the elbow. In: Rockwood & Green’s Fractures in Adults. Philadelphia: Wolters Kluwer; 2015.
Kibler WB, Sciascia A, Uhl TL, et al. In: Delisa’s Physical Medicine and Rehabilitation: Principles and Practice. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2020.
Braddom RL, Buschbacher RM, Chan L, et al. Braddom’s Physical Medicine & Rehabilitation. 6th ed. Philadelphia: Elsevier; 2021.
Oğuz H, Dursun H, Dursun E. Fiziksel Tıp ve Rehabilitasyon. 3. Baskı. Ankara: Güneş Tıp; 2018.
Referanslar
Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: One size does not fit all. J Orthop Sports Phys Ther. 2015;45(11):938–949.
Stasinopoulos D, Johnson MI. Lateral elbow tendinopathy: Evidence of pathophysiology and rationale for management. BMJ. 2021;372:n567.
Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015;61(4):174–181.
Journal of Orthopaedic & Sports Physical Therapy (JOSPT). Clinical Practice Guideline: Lateral Elbow Pain. J Orthop Sports Phys Ther. 2022;52(4):CPG1–CPG32.
Struijs PA, Damen PJ, Bakker EW, et al. Conservative treatment of lateral epicondylitis: Brace versus physical therapy or combination of both. Am J Sports Med. 2004;32(2):462–469.
Mishra A, Skrepnik NV, Edwards S, et al. Platelet-rich plasma for chronic tennis elbow: A double-blind, multicenter, prospective clinical trial. Am J Sports Med. 2014;42(2):463–471.
Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Corticosteroid injection, physiotherapy or wait-and-see for lateral epicondylitis: Randomised controlled trial. BMJ. 2015;349:g7708.
Rabago D, Nourani B. Prolotherapy for osteoarthritis and tendinopathy: A systematic review. Clin Med Insights Arthritis Musculoskelet Disord. 2017;10:1179544117714661.
Rompe JD, Hope C, Küllmer K, et al. Low-energy extracorporeal shock wave therapy for chronic lateral epicondylitis. J Bone Joint Surg Am. 1996;78(3):416–424.
Krey D, Borchers J, McCamey K. Examination, diagnosis, and treatment of chronic lateral epicondylitis. Phys Sportsmed. 2015;43(3):305–313.
Cutts S. Cubital tunnel syndrome. Postgrad Med J. 2007;83(975):28–31.
Gervasio O, Zaccone C, Branca D. Radial tunnel syndrome: Long-term results of surgical treatment. J Hand Surg Br. 2008;33(2):218–220.
Camp CL, Dines JS, Dines DM, et al. Ulnar collateral ligament reconstruction in throwing athletes: A systematic review. Am J Sports Med. 2017;45(3):729–736.
Bernstein J, et al. Ulnar collateral ligament injury: Diagnosis and treatment. J Am Acad Orthop Surg. 2019;27(20):e902–e910.
Safran MR, Graham SM. Distal biceps tendon ruptures: Incidence, mechanism, and outcomes. Clin Orthop Relat Res. 2002;404:275–283.
Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: A systematic review. Am J Sports Med. 2008;36(8):1618–1624.
Baumbach SF, Ploeger MM, Kroonen LT. Olecranon bursitis—An evidence-based review. Orthop Clin North Am. 2014;45(2):145–157.
O’Driscoll SW, Morrey BF. Posterior elbow impingement. Clin Sports Med. 1995;14(1):115–125.
Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Philadelphia: Elsevier; 2018.
Chang EY, Chung CB, et al. MRI of the elbow: Update on ligaments, tendons, nerves, and cartilage. Radiographics. 2014;34(3):673–687.
Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol. 2008;119(9):1951–1965.
Smidt N, Ashworth NL, van der Windt DA, et al. Corticosteroid injections, physiotherapy, or wait-and-see for tennis elbow: Systematic review. Cochrane Database Syst Rev. 2002;(1):CD003528.
Ahmad CS, Grantham WJ, Greiwe RM. Valgus instability of the elbow. J Am Acad Orthop Surg. 2009;17(4):247–258.
Ciccotti MG, Pollack KM, Ciccotti MC, et al. Elbow injuries in throwing athletes: Comprehensive review. Am J Sports Med. 2017;45(1):119–130.
Stull JD, Nicholson BT, et al. MR imaging of nerve entrapment in the elbow. Magn Reson Imaging Clin N Am. 2015;23(1):129–150.
Walker-Bone K, Palmer KT, Reading I, et al. Prevalence and impact of elbow disorders in primary care. Ann Rheum Dis. 2004;63(8):857–872.
Shiri R, Viikari-Juntura E. Lateral & medial epicondylitis: Systematic review & meta-analysis. Am J Epidemiol. 2011;173(3):276–286.
King GJ, Richards RR, Zuckerman JD. Soft tissue disorders of the elbow. In: Rockwood & Green’s Fractures in Adults. Philadelphia: Wolters Kluwer; 2015.
Kibler WB, Sciascia A, Uhl TL, et al. In: Delisa’s Physical Medicine and Rehabilitation: Principles and Practice. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2020.
Braddom RL, Buschbacher RM, Chan L, et al. Braddom’s Physical Medicine & Rehabilitation. 6th ed. Philadelphia: Elsevier; 2021.
Oğuz H, Dursun H, Dursun E. Fiziksel Tıp ve Rehabilitasyon. 3. Baskı. Ankara: Güneş Tıp; 2018.
