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Valgus Extension Overload

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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

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


Risk Factors

  • Throwing sthletes
    • Baseball
    • Softball
  • Non-throwing sports
    • Swimmers
    • Volleyball players
    • Gymnasts
    • Racquet-sport athletes
    • Golfers
  • Duration of career

Differential Diagnosis


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

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


References


  1. Reddy AS, Kvitne RS, Yocum LA, et al. Arthroscopy of the elbow: a long-term clinical review. Arthroscopy 2000;16:588–94.
  2. King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop 1969;67:116–23.
  3. 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.
  4. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995;23:407–13.
  5. 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:
11 November 2020 14:56:10
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