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  • summary
    • Valgus Extension Overload, also known as Pitcher's elbow, is a condition characterized by posteromedial elbow pain related to repetitive microtrauma in throwing athletes.
    • Diagnosis is made clinically with posteromedial elbow pain that worsens with elbow extension, and confirmed with radiographs or advanced imaging showing osteophyte formation on the posteromedial olecranon.
    • First line treatment is nonoperative with rest, activity modifications, and injections. Operative resection of osteophytes and loose bodies are indicated in patients with persistent symptoms.
  • Epidemiology
    • Incidence
      • overall prevalence is unknown, however, may be as high as 65% in elite baseball players with symptomatic elbows
    • Demographics
      • dominant arm in throwing athletes
      • can be seen in non-throwing athletes: swimmers, volleyball players, gymnasts, racquet-sport athletes, and golfers
    • Location
      • posteromedial olecranon
      • posterior trochlea
      • olecranon fossa
  • Etiology
    • Pathophysiology
      • repetitive stress of pitching leads to
        • excessive shear forces on medial aspect of olecranon tip and olecranon fossa
        • lateral radio-capitellar compression
        • posterior extension overload
        • medial tension at MCL
      • pathologic biomechanics leads to
        • cartilage injury from repetitive impaction of olecranon into olecranon fossa
        • osteochondral lesions of the capitellum
        • osteophyte formation 
          • posteromedial humerus
          • olecranon
        • loose bodies from fragmentation
        • UCL can become attenuated with repetitive strain
    • Associated conditions
      • cubital tunnel syndrome
        • concurrent cubital tunnel syndrome in ~25% of cases
  • Presentation
    • Symptoms
      • pain in posteromedial elbow with full extension of elbow
        • pain typically occurs in deceleration / follow-through phase of pitching (rarely during acceleration phase)
        • loss of terminal elbow extension
    • Physical exam
      • palpation
        • tender to palpation over posteromedial olecranon
      • motion
        • flexion contracture
      • provocative tests
        • crepitus due to loose bodies and synovitis in the posterior compartment
        • pain with forced elbow extension
          • sustained elbow extension - "arm bar test"
          • repeated terminal elbow extension - "bounce test"
  • Imaging
    • Radiographs
      • recommended views
        • AP, lateral, oblique of the elbow
      • findings
        • often show osteophyte formation on the posteromedial olecranon
        • loose bodies from fragmentation of capitellum
        • possible calcium deposits on the substance of the MCL
        • hypertrophy of the humerus
          • results in decreased space for articulation of olecranon process within the fossa
    • CT
      • best for demonstrating detailed osseous anatomy
      • 3D reconstructions can be helpful for surgical planning
    • MRI
      • helpful in evaluating associated injuries including partial/complete MCL tears
  • Treatment
    • Nonoperative
      • anti-inflammatory medications, cessation of throwing or offending activities, improvement of throwing mechanics, +/- steroid injections
        • indications
          • first line of treatment 
          • patients who are currently mid-season or are at the end of their competitive careers
        • technique
          • flexor-pronator strengthening
          • pitching instruction to correct poor mechanics
    • Operative
      • arthroscopic osteophyte resection +/- ulnar nerve decompression
        • indications
          • persistent symptoms that fail to improve with nonoperative treatment
        • contraindications
          • MCL insufficiency is a relative contraindication for olecranon debridement alone
        • technique
          • arthroscopy procedures can include debridement or drilling of chondromalacia, debridement of lateral meniscoid lesion or posterolateral plica, osteophyte excision, loose body excision
          • care must be taken to only remove osteophyte and not normal olecranon as this many result in a loss of bony restraint and increase stress on the MCL
        • ulnar nerve release vs. transposition
          • indications
            • significant ulnar nerve symptoms
            • ulnar nerve can be subluxed over medial epicondyle
    • anti-inflammatory medication, cessation of throwing activities, improvement of throwing mechanics +/- steroid injection
      • duration
        • first-time symptomatic patients
          • 10-14 days of active rest
          • followed by graduated throwing program
        • repeat symptomatic patients
          • 4-6 weeks of active rest 
          • followed by a lengthened gradual return to throwing activities
    • Arthroscopic Osteophyte Resection
      • positioning
        • can be performed
          • lateral decubitus
          • prone
          • supine
            • consider supine positioning with articulating arm holder when performing arthroscopic resection in conjunction with MCL reconstruction to ease in transition to open procedure
      • technique
        • mark relevant surface anatomy
          • bony landmarks, portal sites, course of the ulnar nerve and approximate location of posteromedial osteophyte
        • perform routine diagnostic arthroscopy
          • removing any loose bodies encountered and note sites of chondromalacia or osteochondral lesions
        • begin posteromedial osteophyte resection by establishing a posterolateral viewing portal if not already created during diagnostic arthroscopy
        • create direct posterior portal using spinal needle localization passing through skin and triceps tendon
        • identify posteromedial osteophyte and remove overlying fibrous tissue using a combination of radiofrequency ablation and mechanical shaving
        • in cases where the osteophyte is fractured, use an elevator, probe or osteotome to free the fractured osteophyte from the native olecranon
          • when removing the fractured osteophyte, consider switching your working and viewing portals to allow removal of the fragment through the posterolateral portal thus avoiding losing the fragment in the dense triceps tissue
        • using a shaver or burr, contour the olecranon down to its native margin taking care not to over-resect too much bone which can lead to increased stress on the MCL
        • perform an arthroscopic valgus stress test to identify medial gapping which may be indicative of an incompetent MCL
    • Ulnar Nerve Decompression
      • Decompression and Partial Release
      • Transposition for symptomatic, unstable nerves
  • Complications
    • Valgus instability
      • over-resection of the posteromedial osteophyte past its native margin or >3mm may lead to increased stress on the MCL and valgus instability
    • Ulnar nerve injury
      • identify course of the ulnar nerve prior to creation of medial portals and use "nick and spread" technique to avoid iatrogenic ulnar nerve injury
      • when using the shaver or radiofrequency ablation device in the posteromedial gutter, consider judicious use of suction or remove the suction altogether from shaver to avoid iatrogenic ulnar nerve injury
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