| Introduction |
 Repetitive stress of pitching leads to excessive shear forces in and pathology in posteromedial elbow including 
- shear forces on medial aspect of olecranon tip and olecranon fossa
- lateral radio-capitellar compression
- posterior extension overload
- medial tension at MCL
- Epidemiology
- competitive baseball pitchers
- Pathophysiology
- chondrolysis
- osteophyte formation (posteromedial humerus and olecranon)
- loose bodies
- MCL 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 phase of pitch (sometimes during acceleration phase)
- Physical exam
- tender to palpation over posteromedial olecranon
- crepitus
- pain with forced elbow extension
|
| Imaging |
- Radiographs
- recommended views
- AP, lateral, oblique of elbow
- findings
- often show osteophyte formation in the posteromedial olecranon fossa
- loose bodies
- MRI
- helpful in differentiating complete from partial tears of MCL
- CT
|
| Treatment |
- Nonoperative
- NSAIDS, activity modification, steroid injections
- indications
- technique
- pitching instructions to correct poor technique
- Operative
- resection of posteromedial osteophytes, removal of loose bodies, debridement of chondromalacia
- indications
- persistent symptoms that fail to improve with nonoperative treatment
- contraindications
- MCL insufficiency is a relative contraindication for olecranon debridement alone
- technique
- may be arthroscopic or open
- care must be taken to only remove osteophytes and not normal olecranon as this many result in a loss of bony restraint and increase the tension in the MCL
|
| Complications |
- Valgus instability
- resection of too much olecranon may cause valgus instability
|
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Please Rate Educational Value!
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3.0
t-3080
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Average 3.0 of 14 Ratings
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Qbank (2 Questions)
TAG
(OBQ09.261)
In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation?
Review Topic
DISCUSSION:
Valgus extension overload syndrome of the elbow occurs in throwing athletes. The mechanism is thought to be valgus stress on the elbow during acceleration, especially with insufficiency of the medial ulnar collateral ligament. Over time, the continuous impaction of the posterior-medial olecranon in the olecranon fossa can lead to chondromalacia and osteophyte formation.
Wilson et al. described this ostoephyte formation in pitchers which were successfully treated with osteophyte removal.
Illustration A depicts the biomechanics responsible for elbow valgus extension overload syndrome.
Illustrations:
A
REFERENCES:
1.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 101-111
2.
Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88
PMID:6846685 (Link to Abstract)
|
Please Rate Educational Value!
|
4.0
q-3074
|
Average 4.0 of 9 Ratings
|
Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions,
Personal Observations, and Biomechanic Studies)
-
Bell TH, Ferreira LM, McDonald CP, Johnson JA, King GJ. Contribution of the olecranon to elbow stability: an in vitro biomechanical study. J Bone Joint Surg Am. 2010 Apr;92(4):949-57.
PMID:20360520 (Link to Abstract)
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Kamineni S, ElAttrache NS, O’Driscoll SW, Ahmad CS, Hirohara H, Neale PG, An KN, Morrey BF. Medial collateral ligament strain with partial posteromedial olecranon resection. A biomechanical study. J Bone Joint Surg Am. 2004 Nov;86-A(11):2424-30.
PMID:15523013 (Link to Abstract)
Textbooks
- Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
- AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
- Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
- Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
- Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
- Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Undefined
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Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 101-111
-
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.
-
Kamineni S, Hirahara H, Pomianowski S, Neale PG, O'Driscoll SW, ElAttrache N, An KN, Morrey BF. Partial posteromedial olecranon resection: a kinematic study. J Bone Joint Surg Am. 2003 Jun;85-A(6):1005-11.
PMID:12783995 (Link to Abstract)
-
Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88
PMID:6846685 (Link to Abstract)
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