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Arthroscopic Elbow Debridement and Loose Body Removal for Valgus Extension Overload (“Pitcher’s Elbow”)
Valgus extension overload (VEO) occurs when the forces generated by the throwing motion cause the posteromedial tip of the olecranon to impinge upon the medial brim of the olecranon fossa. Repeated impingement in this area causes a stress reaction in the olecranon, which leads to bony overgrowth at the posteromedial tip, worsening the impingement. Pain is experienced in the medial aspect of the elbow during the acceleration phase of throwing, when the valgus forces across the elbow joint are the greatest. Ulnar collateral ligament laxity or injury may cause or exacerbate the symptoms of valgus extension overload. Once a bony prominence has developed on the tip of the olecranon it will not spontaneously disappear. This chapter will review the condition of valgus extension overload and the indications for surgical intervention along with the pre- and postoperative treatment of these patients.
The thrower with medial posterior elbow pain and who has examination and diagnostic findings consistent with VEO should undergo a period of rest from throwing as well as physical therapy for both the shoulder and elbow. In addition, a short course of oral anti-inflammatory medication is indicated. Following 2 to 6 weeks of “active rest,” a gradual return to throwing in a supervised interval throwing program should take place. If the athlete fails to return to painless function, consideration for surgical intervention should be entertained.
Indications
1. VEO with positive examination and diagnostic test findings in a thrower who has failed conservative management
2. Loose bodies that are symptomatic
3. Loss of motion secondary to soft tissue or bony pathology
Contraindications
The contraindications to elbow arthroscopy in the throwing athlete relate to previous procedures.
1. A person who has had previous transposition of the ulnar nerve should not have an anteromedial portal for arthroscopy due to the risk of damage to the nerve.
2. A patient with active septic bursitis or other infectious conditions should not undergo arthroscopy due to the risk of infection of the joint space.
Physical Examination
A thorough history and physical examination are the most important diagnostic tools in the evaluation of the thrower’s elbow. Typical findings in a thrower with valgus extension overload include:
1. VEO test is performed by repeatedly forcing the slightly flexed elbow into hyperextension while applying a valgus stress to the elbow simultaneously. Typically, the patient will report pain on the posteromedial aspect of the elbow if there is impingement.
2. Pain to palpation of the posteromedial tip of the olecranon.
3. History of decreased performance in throwing with pain reported during the acceleration phase of the throwing motion.
Diagnostic Tests
1. Standard anteroposterior (AP), lateral, axial, and oblique radiographs of the elbow are the first part of the diagnostic workup.
2. If medial instability is suspected, stress AP radiographs can be obtained using a specialized stress machine. Bony prominences on the olecranon tip will generally be seen well on standard radiographs (Figs. 40–1A,B).
3. A computed tomography scan may be utilized if stress fracture of the olecranon or loose bodies are suspected.
4. Magnetic resonance imaging with contrast should be obtained to determine the integrity of the ulnar collateral ligament.
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