Updated: 11/14/2018

Valgus Extension Overload (Pitcher's Elbow)

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Evidence
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Introduction
  • A condition characterized by pathology in posteromedial elbow, common in throwing athletes
  • Epidemiology
    • demographics
      • dominant arm of baseball pitchers 
  • 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 and olecranon)
      • loose bodies from fragmentation
      • 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) 
      • loss of terminal elbow extension
  • Physical exam
    • tender to palpation over posteromedial olecranon
    • crepitus 
    • pain with forced elbow extension
    • flexion contracture
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, oblique of elbow
    • findings
      • often show osteophyte formation in the posteromedial olecranon fossa 
      • 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
    • shows osseous pathology best
  • MRI 
    • helpful in evaluating associated injuries including partial/complete MCL tears
Treatment
  • Nonoperative
    • NSAIDS, throwing rest, activity modification, steroid injections 
      • indications
        • first line of treatment
      • technique
        • flexor-pronator strengthening
        • 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
        • 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 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 
  • Ulnar nerve damage
 

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Questions (8)
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(SAE07SM.50) A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain? Review Topic

QID: 8712
1

Ulnar neuritis

2%

(1/47)

2

Excessive olecranon resection

43%

(20/47)

3

Osteochondritis dissecans of the capitellum

2%

(1/47)

4

Olecranon stress fracture

0%

(0/47)

5

Valgus extension overload

47%

(22/47)

N/A

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(OBQ12.90) A 23-year-old right hand dominant minor league baseball pitcher presents with symptoms of right elbow valgus instability. Nine months ago the patient underwent a procedure to remove osteophytes from his right elbow. A preoperative MRI of the right elbow is found in Figure A. Which structure is likely damaged? Review Topic

QID: 4450
FIGURES:
1

Lateral ulnar collateral ligament

14%

(691/4956)

2

Radial collateral ligament

2%

(75/4956)

3

Annular ligament

1%

(45/4956)

4

Arcuate ligament

1%

(57/4956)

5

Medial collateral ligament

82%

(4047/4956)

ML 2

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(OBQ09.261) In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation? Review Topic

QID: 3074
FIGURES:
1

A

4%

(67/1696)

2

B

7%

(123/1696)

3

C

22%

(367/1696)

4

D

61%

(1040/1696)

5

E

5%

(93/1696)

ML 4

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