Valgus Extension Overload (VEO), also known as throwers arm, happens when the elbow is overused, resulting in deterioration and the development of bone spurs. VEO also causes pain, swelling, and possible numbness. While it is possible for anyone to get VEO, throwing athletes are most vulnerable.
The valgus overload is then accentuated, and excessive valgus moments may lead to a stretch of the other medial structures, resulting in ulnar neuritis, flexor-pronator mass tendinopathy, or medial epicondyle apophysitis in the skeletally immature patient. The non-operative treatment for valgus extension overload injuries includes rest, anti-inflammatory medicine, correction of improper throwing mechanics, and a rehabilitation program to strengthen and coordinate the muscles acting across the elbow.
There are several preventative techniques that will help to prevent throwers’ elbows, including bracing and strapping, modifying equipment, taking extended rests, and even learning new routines for repetitive activities.
Other Names
- Valgus Extension Overload Syndrome
- Posterior Impingement
- Thrower’s Elbow
- VEO
- Pitcher’s Elbow
- Posterior Elbow Impingement
Pathophysiology
- Occurs in the overhead athlete or throwing athlete as a result of chronic overuse
- 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-capitellar 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
- Olecranon of proximal Ulna articulates with Olecranon Fossa of distal Humerus
- Ulnar Collateral Ligament
- The 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 the 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)
- Throwing athletes
- Baseball
- Softball
- Non-throwing sports
- Swimmers
- Volleyball players
- Gymnasts
- Racquet-sport athletes
- Golfers
- Duration of career
Differential Diagnosis
- Fractures
- Adult
- Radial Head Fracture
- Olecranon Fracture
- Capitellum Fracture
- Coronoid Fracture
- Terrible Triad of Elbow
- Pediatric
- Nursemaids Elbow
- Supracondylar Fracture
- Lateral Condyle Fracture (Peds)
- Medial Condyle Fracture (Peds)
- Olecranon Fracture (Peds)
- Radial Head Fracture (Peds)
- Medial Epicondyle Fracture (Peds)
- Salter Harris Fracture
- Adult
- Dislocations & Instability
- Elbow Dislocation
- Proximal Radioulnar Joint Instability
- Tendinopathies
- Lateral Epicondylitis
- Medial Epicondylitis
- Distal Biceps Tendon Injury
- Triceps Tendon Injury
- Bursopathies
- Olecranon Bursitis
- Ligament Injuries
- Lateral Collateral Ligament Injury (Elbow)
- Ulnar Collateral Ligament Injury
- Neuropathies
- Cubital Tunnel Syndrome
- Radial Tunnel Syndrome
- Arthropathies
- Elbow Arthritis
- Other
- Valgus Extension Overload
- Posteromedial Rotatory Instability
- Posterolateral Rotatory Instability
- Osteochondral Defect
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Diagnosis
- General: Physical Exam Elbow
- History
- A thorough review of patients throwing history
- Review biomechanics with the patient and when pain occurs
- The pain classically occurs during the deceleration phase at terminal extension in the throwing cycle
- Loss of terminal extension
- Physical
- Tender over the posteromedial olecranon
- Crepitus
- Repeatedly placing a valgus stress on the elbow at 20° to 30° of flexion while forcing the elbow into terminal extension
- 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
Treatment
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
- Corticosteroid Injection
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
