Review Question - QID 216887

This pitcher likely has valgus extension overload syndrome (VEO), which is characterized by posteromedial elbow pain, loss of extension and posteromedial osteophytes on radiographs.

VEO is an elbow condition which is related to the forceful, repetitive movements employed by overhead throwers. It is thought to occur as increased forces are placed through the medial olecranon and olecranon fossa, leading to cartilage injury and eventually osteophyte formation. This can eventually lead to loose body formation and even worsen to the point of causing ulnar collateral ligament (UCL) attenuation. On examination, patients typically have decreased terminal extension, as posteromedial osteophytes prevent full seating of the olecranon in the fossa. Radiographs are useful to identify these osteophytes. MRI is not necessary to diagnose VEO but may be useful if there is concern for concomitant capitellar OCD or UCL injury. Ultimately, rest from throwing, activity modification and NSAIDS are the first line treatment with arthroscopic intervention becoming necessary in patients with persistent pain. This being said, it is important to only remove osteophytes and not native medial olecranon as this can place more stress on the UCL and lead to valgus instability.

Wilson et al. recognized VEO in the pitching elbow of elite baseball players, noting that the pain often occurred between the acceleration and follow-through of the throwing motion. They identified the characteristic posteromedial olecranon osteophyte in all 5 players studied, with the authors theorizing this impinged on the olecranon fossa and caused cartilage wear. They concluded that removal of these osteophytes and debridement of cartilage wear could lead to good results and return to sport.

Andrews et al. reviewed lesions of the posterior elbow compartments. In this article, they specifically review complications related to VEO as well as the anatomy and biomechanics related to this condition. They conclude that these lesions can be addressed with elbow arthroscopy if nonoperative treatment fails.

Reddy et al. reviewed elbow arthroscopy to better establish efficacy and risks of the procedure. The most common indication was posterior impingement which was present in 51% of cases. They noted 92% of patients had excellent or good outcomes and there was a low rate (1.6%) of complication. The concluded that, when indicated, elbow arthroscopy is a useful tool in treating a variety of conditions with high rates of satisfaction and return to activity.

Figures A & B demonstrate the radiographs of an elbow with posteromedial osteophyte formation, characteristic of VEO. note that there is an ossification within the proximal UCL, a common finding in the older elite throwers. Illustration A demonstrates a diagram that shows the mechanism by which osteophytes normally form in VEO.

Incorrect Answers:
Answer 1: Medial epicondyle avulsion fractures occur in skeletally immature individuals and are usually identified on radiographs or MRI.
Answer 2: Olecranon stress fractures present with posterior arm pain and swelling and is usually identifiable on a lateral elbow radiograph or MRI.
Answer 3: Osteochondral defects of the medial trochlea are uncommon and not seen in this patient. Capitellar OCDs can occur concomitantly with valgus overload or instability.
Answer 4: Medial epicondylitis would not result in the characteristic radiographs seen in VEO and would be unlikely to cause a flexion contracture. Pain with resisted flexion/pronation would be more diagnostic of medial epicondylitis.