Valgus Extension Overload (Pitcher's Elbow)

Topic updated on 01/12/14 11:52am
  • A condition characterized by pathology in posteromedial elbow
  • Epidemiology
    • demographics
      • competitive 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
      • chondrolysis
      • osteophyte formation (posteromedial humerus and olecranon)
      • loose bodies
      • MCL can become attenuated with repetitive strain
  • Associated conditions
    • cubital tunnel syndrome 
      • concurrent cubital tunnel syndrome in ~25% of cases
  • Symptoms
    • pain in posteromedial elbow with full extension of elbow
      • pain typically occurs in deceleration phase of pitch (sometimes during acceleration phase) 
  • Physical exam
    • tender to palpation over posteromedial olecranon
    • crepitus 
    • pain with forced elbow extension
  • Radiographs
    • recommended views
      • AP, lateral, oblique of elbow
    • findings
      • often show osteophyte formation in the posteromedial olecranon fossa 
      • loose bodies
  • MRI 
    • helpful in differentiating complete from partial tears of MCL
  • CT
    • shows pathology best
  • Nonoperative
    • NSAIDS, activity modification, steroid injections
      • indications
        • first line of treatment
      • technique
        • 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
        • 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 
  • Valgus instability
    • resection of too much olecranon may cause valgus instability 


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Qbank (3 Questions)

(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? Topic Review Topic
FIGURES: A          

1. Lateral ulnar collateral ligament
2. Radial collateral ligament
3. Annular ligament
4. Arcuate ligament
5. Medial collateral ligament

(OBQ09.261) In valgus extension overload of the elbow, which letter in Figure A corresponds to the typical location of osteophytes formation? Topic Review Topic
FIGURES: A          

1. A
2. B
3. C
4. D
5. E

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