Review Question - QID 219895

Valgus Extension Overload (Pitcher's Elbow) Presentation Symptoms QID: 219895 (SBQ24SE.40)

QID 219895 (Type "219895" in App Search)

A 22-year-old collegiate football quarterback presents to the office for evaluation of left elbow pain. For the last two months, the patient has reported pain in his posteromedial elbow when throwing the football. Only recently has he begun to notice decreased accuracy of his throws. Radiographs are obtained, as demonstrated in Figure A. During which phase of throwing does this entity elicit the most pain?

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Wind-up

1/463

Early cocking

23/463

Late cocking

63%

290/463

Acceleration

10%

44/463

Follow-through

22%

102/463

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This 22-year-old is exhibiting findings suggestive of valgus extension overload syndrome. The phase of throwing where the patient is most symptomatic is during the deceleration and follow-through phases (Answer 5).

Valgus extension overload (VEO) syndrome is becoming increasingly recognized in throwing athletes. The condition is characterized by posteromedial elbow pain during repetitive stress, namely throwing. Repeated insult to the elbow can manifest in several ways, but most commonly as posteromedial olecranon and humeral osteophyte formation. Anteroposterior radiographs are key to making the diagnosis, as one will observe osteophyte formation on the medial portion of the olecranon. The pathological bone formation in these areas serves as the basis for why throwers are symptomatic with the deceleration/follow-through phases, as the medial olecranon osteophyte impinges onto the humerus within the medial olecranon fossa. With continued symptoms resistant to nonoperative treatment or diminished athletic performance, patients can undergo arthroscopic osteophyte resection with possible ulnar nerve decompression if ulnar nerve symptoms are present.

Ahmad and Conway review VEO, examining its pathophysiology, symptomatology, diagnostic work-up, and treatment. The authors note posteromedial elbow pain during the deceleration/follow-through phases of throwing. Furthermore, they recommend a thorough evaluation, including the competency of the medial ulnar collateral ligament, as failure of this ligament can lead to valgus instability. Ultimately, they recommend surgical intervention only after failure of extended nonsurgical treatment, which would involve either arthroscopic (preferred) or open cheilectomy.

Wilson et al. report on a case series of five baseball pitchers (three college, two professional) who exhibited pain in the follow-through phases of pitching, which ultimately led to a decrease in performance. On imaging, all displayed posteromedial olecranon osteophyte. Each case was subsequently treated with surgical excision of posterior osteophyte through the posterolateral approach, and all pitchers were able to return to pitching thereafter.

Figure A represents an AP view of a right elbow demonstrating posteromedial olecranon osteophyte.

Incorrect Answers:
Answers 1-4: these phases are not found to elicit pain in those with VEO