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Valgus Extension Overload
From WikiSM
Other Names
- Valgus Extension Overload Syndrome
- Posterior Impingement
- Thrower's Elbow
- VEO
- Pitcher's Elbow
- Posterior Elbow Impingement
Background
- Condition that results from impingement of the posteromedial tip of the Olecranon process on the medial wall of the olecranon fossa
- Commonly seen in the throwing or overhead athlete
Epidemiology
- Most commonly occurs in dominant arm of baseball pitchers
- In published a series of nearly 200 elbow arthroscopies, more than 50% had posterior impingement[1]
Pathophysiology
- Occurs in the overhead athlete or throwing athlete as a result of chronic overuse[2]
- Likely occurs over months to years
- Repetitive stress of throwing leads to:
- Increase in medial elbow ligamentous laxity
- Predispose the athlete to repetitive microtrauma of the olecranon tip within the fossa as the elbow is forcibly extended.
- Excessive valgus force
- Posteromedial Impingement leads to osteophyte formation posteromedial tip of the olecranon
- Lateral radio-capitallar compression
- Subsequent pathologic changes include
- Cartilage injury from olecranon-olecranon fossa repetitive impaction
- Osteochondral lesions of the capitellum
- Osteophyte formation, loose bodies
Pathoanatomy
- Elbow Anatomy
- Ulnar Collateral Ligament
- Main stabilizer of medial elbow
- UCL may be lax or completely rupture
Biomechanics
- During throwing, the elbow experiences an average of 64 Nm of valgus stress
- 50% is taken up by the UCL[3]
- As elbow extends, the endpoint is the Olecranon colliding into the olecranon fossa
- Biomechanical factors that increase risk
- Late trunk rotation
- Reduced shoulder external rotation
- Increased elbow flexion
- Sidearm pitching
Associated Injuries
- Ulnar Collateral Ligament Injury
- Cubital Tunnel Syndrome
- Approximately 1/4 of cases (need citation)
Risk Factors
- Throwing sthletes
- Baseball
- Softball
- Non-throwing sports
- Swimmers
- Volleyball players
- Gymnasts
- Racquet-sport athletes
- Golfers
- Duration of career
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- General: Physical Exam Elbow
- History
- Thorough review of patients throwing history
- Review biomechanics with patient and when pain occurs
- Pain classically occurs during the deceleration phase at terminal extension in the throwing cycle
- Loss of terminal extension
- Physical
- Tender over posteromedial olecranon
- Crepitus
- Repeatedly placing a valgus stress on the elbow at 20° to 30° of flexion while forcing the elbow into terminal extension
Evaluation
- Radiology
- Standard 3 view elbow
- Can find
- Olecranon osteophytes in the posteromedial olecranon fossa, found in 65% of the cases[4]
- Loose bodies
- Calcium deposits in the UCL
- Hypertrophy of the humerus
- CT
- Useful to evaluate bony pathology
- MRI
- Useful to confirm diagnosis, exclude other pathology
- Helpful to evaluate UCL, soft tissue
Classification
- N/A
Management
Nonoperative
- First line therapy
- Active rest, avoiding provocative activities
- Physical Therapy targeting rotator cuff strength, flexor-pronator strength
- Biomechanical corrections to throwing
- Medications including NSAIDS, Acetaminophen
- Not recommended
Operative
- Indications
- Consider when conservative measures fail to relieve symptoms
- Technique
- Elbow arthroscopy
- arthroscopic shaver or burr to remove the posteromedial tip of the olecranon
Rehab and Return to Play
Rehabilitation
- First presentation
- Remove from play for 10-14 days
- Gradual progression through throwing program
- Multiple or recurrent symptoms
- Prolonged period of rest before beginning throwing program
- Postoperative program[5]
- 2 weeks: sutures removed, work on range of motion
- 3-4 weeks: range of motion returned
- 4-6 weeks:
- Begin some plyometric exercises designed to gently stress the tissues around the elbow joint
- The athlete is allowed to begin the interval throwing program
Return to Play
- Postoperatively
- Typically 3-6 months
- At discretion of surgeon
Complications
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ Reddy AS, Kvitne RS, Yocum LA, et al. Arthroscopy of the elbow: a long-term clinical review. Arthroscopy 2000;16:588–94.
- ↑ King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop 1969;67:116–23.
- ↑ Fleisig GS, Andrws JR, Dillman CJ, et al. Kinetics of baseball pitching with implication about injury mechanisms. Am J Sports Med 1995;23:233–9.
- ↑ Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995;23:407–13.
- ↑ Dugas, Jeffrey R. "Valgus extension overload: diagnosis and treatment." Clinics in sports medicine 29.4 (2010): 645-654.
Created by:
John Kiel on 18 June 2019 01:54:11
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Last edited:
13 October 2022 14:06:31
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