Bone & Joint Expert Care

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Valgus extension overload

What is valgus extension overload?

Valgus extension overload (VEO) syndrome is a condition seen in throwing athletes, in which repetitive stresses of throwing lead to progressive changes within the elbow joint, which cause pain and athletic impairment.

How does VEO occur?

In the throwing motion, a substantial amount of force is generated over the medial (inside) aspect of the elbow. Over time, such stresses can lead to breakdown of the cartilage on the olecranon (the bony tip of the elbow that engages the distal humerus (end of the arm bone).

Eventual breakdown of the cartilage can lead to unstable body formation, development of bony osteophytes (spurs) and, in many cases, loss of normal elbow extension. Forces can also compromise the most important restraint on the medial side of the elbow, the ulnar collateral ligament (UCL). Injury to the UCL can precipitate or exacerbate VEO due to increased loading of the aticular surfaces.

What increases the risk?

  • Overhead throwing activities, especially those performed with sudden and forceful elbow extension (most commonly pitching though it can be any baseball position player·· also the motions of· the javelin, hockey slap shot, tennis serve and volleyball serve/spike)
  • Improper mechanics
  • Inadequate physical conditioning (strength and flexibility)

What are the symptoms of VEO?

  • Pain and tenderness around the elbow (inner, outer or back of the elbow), especially when trying to throw or straighten the elbow
  • Occasionally, locking or catching of the elbow
  • Swelling within the elbow joint
  • Loss of normal extension (ability to straighten the elbow)
  • Inability to throw at full speed; loss of ball control
  • Occasionally, there is associated stress on the ulnar nerve (the funny bone), which is vulnerable to the same stresses and overload that lead to VEO. This can present as numbness or tingling in the ring and little fingers, with clumsiness and weakness in gripping.

How is VEO diagnosed?

Diagnosis is made by history and physical exam. X-rays are important to demonstrate the ostephytes (bone spurs) and, when present, loose bodies within the elbow.

Are there any special tests?

MRI is often indicated to evaluate integrity of the UCL, as well as document the extent of the ostephytes and any other pathology within the elbow.

How is VEO treated?

Non-operative treatment is appropriate in early stages. Rest, anti-inflammatory medication, gentle stretching and gradual return to throwing (or other sport) is effective for many patients. At a more elite level, presentation of a locked elbow that doesn’t straighten, and is accompanied by X-rays showing loose bodies, operative treatment is often warranted.

Operative treatment is indicated for those refractory to non-operative management and those with restricted motion and loose bodies. Arthroscopic surgery, in which a small camera is introduced into the elbow joint, permits removal of loose bodies and debris and shaving of any bone spurs that have formed.

The most important consideration in surgical intervention is identifying those individuals whose UCL also may require operative treatment to reconstruct the damaged ligament. If symptoms persist, or if there is locking and catching, which are due to loose bone fragments within the joint, arthroscopic surgery is recommended. Surgery is performed to remove bone spurs, bone fragments and loose cartilage.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms upon return to athletic activity, particularly amongst those with UCL pathology
  • Athletic impairment, such as inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too quickly after injury
  • Inability to return to the same level of sports
  • Injury to other structures of the elbow, including medial epicondylitis and strain of the muscle-tendon of the muscles that bend the wrist
  • Prolonged disability
  • Elbow stiffness (loss of elbow motion)
  • Arthritis of the elbow

Possible complications of operative treatment include:

  • Recurrent symptoms upon return to athletic activity, particularly amongst those with UCL pathology
  • Athletic impairment, such as inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too quickly after injury
  • Persistent elbow stiffness (loss of elbow motion)
  • Arthritis of the elbow 
  • Surgical complications not specifically associated with VEO, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity- 

When can you return to your sport or activity?

Resolution of symptoms and recovery of motion permit resumption of a throwing (or other activity, as appropriate) program. Return following surgery may be as early as 4 weeks, but requires resolution of pain, swelling, restoration of motion and ability to tolerate resumption of athletic activity.

How can VEO be prevented?

  • Appropriately warm up and stretch before practice and competition
  • Maintain appropriate conditioning:
    • Arm, forearm, and wrist flexibility
    • Muscle strength and endurance
  • Use proper technique when throwing, serving or hitting a puck