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 showing osteophyte formation in the posteromedial olecranon fossa. Treatment is usually nonoperative with rest, activity modifications, and injections. Operative resection of osteophytes and loose bodies are indicated in pitchers with persistent symptoms. Epidemiology Demographics dominant arm of baseball pitchers 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 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
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4450 FIGURES: A Type & Select Correct Answer 1 Lateral ulnar collateral ligament 14% (844/5873) 2 Radial collateral ligament 1% (88/5873) 3 Annular ligament 1% (59/5873) 4 Arcuate ligament 1% (60/5873) 5 Medial collateral ligament 81% (4774/5873) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.261) In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation? QID: 3074 FIGURES: A Type & Select Correct Answer 1 A 4% (89/2262) 2 B 7% (155/2262) 3 C 22% (495/2262) 4 D 61% (1377/2262) 5 E 6% (138/2262) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ07SM.50) Figure A exhibits arthroscopic images during posterior debridement of an overhead athlete. Excessive resection and removing normal olecranon most likely will lead to what pathology when returning to play? QID: 1435 FIGURES: A Type & Select Correct Answer 1 Medial epicondylitis 1% (28/3006) 2 Valgus elbow instability 54% (1610/3006) 3 Lateral epicondylitis 1% (20/3006) 4 Posterolateral rotatory instablity 25% (748/3006) 5 Olecranon stress fracture 20% (588/3006) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (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? QID: 8712 Type & Select Correct Answer 1 Ulnar neuritis 2% (12/557) 2 Excessive olecranon resection 49% (272/557) 3 Osteochondritis dissecans of the capitellum 3% (17/557) 4 Olecranon stress fracture 3% (19/557) 5 Valgus extension overload 42% (232/557) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (3) Podcasts (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2018-2019 Elbow Throwing Conditions - Dayton Opel, MD Dayton Opel Shoulder & Elbow - Valgus Extension Overload (Pitcher's Elbow) 10/1/2020 31 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts Valgus Extension Overload - Mark Schickendantz, MD (BSM 2018, #27) Mark Schickendantz Shoulder & Elbow - Valgus Extension Overload (Pitcher's Elbow) B 12/21/2018 278 views 4.5 (2) Login to View Community Videos Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts Current Concepts in Workload Monitoring: When Does a Day Off Prevent Injury and Enhance Performance? - Brandon J. Erickson, MD (BSM 2018, #23) Brandon Erickson Shoulder & Elbow - Valgus Extension Overload (Pitcher's Elbow) C 12/21/2018 85 views 0.0 (0) Shoulder & Elbow⎪Valgus Extension Overload (Pitcher's Elbow) Team Orthobullets 4 Shoulder & Elbow - Valgus Extension Overload (Pitcher's Elbow) Listen Now 8:46 min 10/15/2019 148 plays 5.0 (1)
Radiocapitellar plica and posteromedial impingement in 27M (C101693) Matthew J. Steffes Shoulder & Elbow - Valgus Extension Overload (Pitcher's Elbow) B 1/11/2021 112 9 0