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

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

Complications

Valgus instability
- resection of too much olecranon may cause valgus instability
Ulnar nerve damage