Valgus Extension Overload (Pitcher's Elbow) - Shoulder & Elbow

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

TECHNIQUES
- 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

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T