Valgus Extension Overload of the Elbow

• Sport-specific: Predominantly overhead throwing athletes (baseball pitchers, javelin, cricket fast bowlers)
• Age: Typically ages 18-35 (peak competitive years)
• Incidence: Up to 90 percent of professional baseball pitchers have radiographic evidence of posteromedial osteophytes
• Bilateral: Dominant arm affected; non-dominant arm may show similar but milder changes

• Late cocking phase: Peak valgus torque of 50-74 Nm at the elbow
• Early acceleration: Maximum angular velocity and valgus stress
• Terminal extension: Olecranon tip engages in fossa at terminal 10-20 degrees
• Posteromedial shear: Valgus combined with extension concentrates force on medial olecranon

• Sport: Overhead throwing (baseball pitcher, javelin, cricket fast bowler, tennis serve)
• Symptom: Posteromedial elbow pain during terminal extension
• Mechanical symptoms: Clicking, catching, locking (suggest loose bodies)
• Velocity loss: Decreased throwing velocity or accuracy
• Duration: Insidious onset over months to seasons (chronic)
• Medial symptoms: Tingling in ring and small fingers raises concern for ulnar neuritis

• Inspect: Carrying angle, medial swelling, muscle atrophy
• Palpate: Posteromedial olecranon tip tenderness (key finding), medial epicondyle, UCL
• Range of motion: Terminal extension painful, possible mechanical block
• Valgus stress testing: Moving valgus stress test, gravity valgus test, milking test
• Special test: Valgus extension snap test (reproduces posteromedial pain)

• Baseball pitchers: Highest incidence worldwide (USA, Japan, Korea, Caribbean, Latin America)
• Javelin throwers: Significant prevalence in European and Commonwealth nations
• Cricket fast bowlers: Increasingly recognised in cricket-playing nations worldwide (England, South Asia, the West Indies, Australia)
• Other overhead sports: Tennis serve, volleyball spike, handball throwing motion
• Up to 90 percent of professional baseball pitchers have radiographic posteromedial osteophytes

• High-resource (USA, Japan, Australia): MRI and dynamic ultrasound for UCL assessment; advanced arthroscopic techniques with throwing mechanics analysis and biomechanical labs
• Limited-resource: Radiographs and clinical examination for diagnosis; open debridement when arthroscopy unavailable; rehabilitation-based management emphasised
• Universal principle: UCL integrity assessment is mandatory regardless of resource setting - the clinical examination (moving valgus stress test) is the most important tool
• Return-to-sport protocols: Standardised interval throwing programs are used globally regardless of resource level

Partial undersurface UCL tears pose a dilemma: some can be managed with rehabilitation and augmented repair, while others progress to require reconstruction. No consensus exists on the threshold for reconstruction versus repair in the context of simultaneous VEO. Decision-making is individualised based on sport, level of competition, and biomechanical demands.

The safe limit of posteromedial olecranon resection is debated. Biomechanical studies suggest that resection exceeding 4-6 mm of normal olecranon beyond the osteophyte may compromise stability. Intra-operative fluoroscopy and CT-based templating are recommended, but the exact limits vary by individual anatomy.

Internal brace augmentation (collagen-coated tape) during UCL reconstruction may allow accelerated rehabilitation, but long-term outcome data specific to VEO patients is limited. This technique is gaining acceptance in high-level throwing athletes.

PRP and stem cell injections for partial UCL tears and chondral damage associated with VEO remain investigational. Some centres report promising early results, but high-quality trials are lacking. These adjuncts should not replace established surgical principles.