The preoperative evaluation should focus on a thorough history and physical examination, followed by use of specific diagnostic imaging modalities. One of the greatest challenges when examining an injured athlete is ensuring that the examination encompasses the whole patient and not just the obvious deformity. The illegal use of drugs to enhance performance is widely known in sports, however the administration of illegal substance may not be the only dishonest way to enhance athlete's performance. Current epidemiology, anatomy, diagnosis (physical exam, imaging), and treatment (injections, surgery, and rehabilitation) of UCL injury are discussed. Man könnte behaupten, dass die Untersuchung und die Interpretation der Ergebnisse im Bereich des Ellenbogens im Gegensatz zur Schulter oder zum Handgelenk nicht sonderlich kompliziert erscheinen – dass dem nicht so ist, zeigt sich täglich aufs Neue. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. An understanding of the anatomy of the elbow and the biomechanics of throwing is essential to making the correct diagnosis and instituting proper care. Ice, anti-inflammatory medications, and even physical therapy can be helpful for early symptoms of valgus extension overload. Level of evidence: A total of 200 baseball players (198 male, 2 female; mean age, 16.1 years; age range, 13-27 years) who were diagnosed with an OSF from January 1987 to July 2012 were studied. Three methods of spur resection have been published, and all have good outcomes with small patient numbers and limited follow-up. This study presents the results of the arthroscopic plication of the radial component of the lateral collateral ligament (R-LCL) to reduce minor instability of the lateral elbow. Sports injuries of the upper extremity are a common problem seen by those who care for athletes and those who manage upper extremity injuries. Post-operative median quickDASH was 9.1 [0–25] points and OES 42 [34–48]. A revived dedication to the physical examination may enhance our ability to correctly diagnose various pathologies about the elbow. Conclusion: Ten cadaveric arms underwent posterior olecranon resection in 4-mm increments. Purpose: Accurate diagnosis and proper treatment of elbow injuries in the throwing athlete requires a thorough understanding of elbow function and anatomy, as well as an understanding of throwing mechanics and pathomechanics. The imaging modalities of these 31 players including radiography, CT, and MRI were reviewed by 2 experienced musculoskeletal radiologists. Valgus extension overload (VEO) is a constellation of symptoms and pathology commonly seen in the overhead athlete. The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies, and pertinent data were abstracted. Average postoperative pain VAS and MEPS had been changed into 0.4 (p<0.001) and 97.5 (p<0.001). "Valgus extension overload syndrome" refers to the clinical syndrome which may be seen in adolescent or skeletally-mature athletes. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist. Both knowledge of throwing mechanics and understanding of normal bone development in the immature skeleton are key to the diagnosis, treatment, and potential prevention of these common injuries. Posterior elbow pain is a common problem in the throwing athlete due to adaptive bony and soft tissue changes in response to valgus extension overload (VEO) syndrome. We predict that the KJOC score in our general throwing population will provide an accurate assessment of postoperative outcomes consistent with previously published reports. R-LCL plication was performed in the presence of at least one sign of lateral ligamentous patholaxity and one intra-articular abnormal finding. Most athletes improve substantially with rest and nonoperative treatment, although some athletes may require surgical intervention to return to play. To read the full-text of this research, you can request a copy directly from the author. In addition to providing a review of UCL reconstruction outcomes, we provide a description of the docking technique, the authors preferred method of UCL reconstruction. There was a significant yearly increase in the number of UCL reconstructions (P < .001) performed in New York State from 2002 to 2011. We believe that the technique and the identification of anatomic structures described in this article provide a safe and reliable means of performing this procedure. Both of these conditions are treated initially with rest from throwing, followed by gradual return to throwing through an interval throwing program. It provides the wide field of view necessary for both diagnostic and operative elbow arthroscopy. When surgery is required, modern techniques utilizing a flexor–pronator splitting approach have provided consistent results, with return to sport rates of 90 % frequently reported, while avoiding ulnar nerve symptoms that plagued early reconstructions. The average modified Figgie score increased from 31.2 points (range, 22-43) to 46.9 (range, 29-50) postoperatively in professional athletes; from 26.3 to 42.6 in patients who had Workers' Compensation claims but were not professional athletes; from 29.4 to 45.6 in patients with a diagnosis of loose bodies; and from 30.1 to 43.7 in patients with degenerative joint disease. With proper attention to anatomical landmarks for portal placement and meticulous surgical technique, arthroscopic evaluation and treatment of posterior elbow pain can be safely accomplished in the throwing athlete with minimal risk. Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). Sixty-nine adult baseball players pitched off an indoor mound during 3-dimensional motion analysis to measure whole body kinematics and kinetics at 240 Hz. The volume of UCL reconstructions increased by 193%, and the rate per 100,000 population tripled from 0.15 to 0.45. This stress can cause structural damage and injury to the ulnar collateral ligament. A thorough history and physical examination of the thrower's elbow frequently establishes the diagnosis for pain. We reviewed the records of 72 professional baseball players who underwent arthroscopic or open elbow surgery. Five baseball pitchers, three college and two professional, with an average age of 24 years, exhibited pain between the acceleration phase and follow-through phase of the pitching motion. Athletes involved in sporting activities can suffer acute injuries or can develop overuse injuries that affect the elbow. The primary endpoint was the yearly rate of UCL reconstruction over time; secondary endpoints included patient demographics, institution volumes, and concomitant procedures on the ulnar nerve. A condition of late trunk rotation, reduced shoulder external rotation, and increased elbow flexion appeared to be most closely related to valgus torque. The surgical treatment involves posterior olecranon osteophyte resection. Level 4. All patients had their charts and radiographs reviewed, and 104 of these patients were also contacted for a telephone interview at an average follow-up of 42.3 months (range, 7 to 115 months). This laxity may cause bony abutment and impingement within the olecranon fossa, which in turn create posteromedial osteophytes. This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane. In: Baker C Jr, Plancher K, eds. In particular, valgus extension overload during the throw-ing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-perfor-mance athletes. Failure of. Results: eight patients were operated on, four of them presented with neuropathy from compressed cubital nerve at the elbow; four underwent transfer of their cubital nerve, two subcutaneous and two with a pulley with flexor pronator fascia. This condition is one of many that frequently occur in the thrower’s elbow and often does not occur in isolation. The ulnar nerve should be palpated for possible subluxation and Tinel’s Overuse and inadequate rest are salient risk factors for injury. Return to previous level of competition can be expected in a high percentage of cases; however, the incidence of additional future surgical procedures is as high as 30–40 %. Athletes in many sports may experience VEO and other common pathologies related to the high repetitive stresses generated by the overhead throwing motion. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain. On the basis of these data, we conclude that the effect of medial olecranon osteotomy on ulnar collateral ligament strain may be small. Conclusion We retrospectively reviewed a convenient sample of 172 patients who underwent 187 arthroscopies of the elbow over a 7-year period. Information quality depends on the search term used, website authorship, and commercial bias. Valgus extension overload syndrome, also known as pitcher's elbow, refers to a constellation of symptoms and pathologies commonly seen in overhead throwing athletes secondary to high repetitive tensile, shear and compressive forces generated by the overhead throwing motion. The term "high-level athlete" may include adolescents and high school students, collegiate athletes, and of course, the professional athlete. Methods: Average preoperative pain VAS and MEPS were 5.5 and 67.5. performing a safe examination and in avoiding damage to the neurovascular structures. Study design: We evaluated 113 unique websites. PurposeLateral epicondylitis is generally considered an extra-articular condition. There is no substitute for a careful clinical history and physical examination in not only establishing the diagnosis but ensuring that a complete diagnosis with its subsequent prognostic outcome can be rendered. Abstract Injury to the medial collateral ligament of the elbow (MCL) can be a career-threatening injury for an overhead athlete without appropriate diagnosis and treatment. Conclusion: Study Design No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Results: Valgus Extension Overload Syndrome: Review Anant Singh Valgus extension overload syndrome of the elbow is common among throwing athletes and commonly results from repetitive valgus torque and deceleration across the elbow We described 24 test procedures of which 14 tests contained data on diagnostic accuracy. Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. It is essential for radiologists to understand the normal and abnormal imaging appearances after UCL reconstruction and ulnar nerve transposition, which is also commonly performed in overhead-throwing athletes. Results: The following chapter provides an overview of the relevant anatomy, biomechanics, and diagnosis of VEO. Website quality and accuracy were lower with use of the search term "pitcher's elbow" as compared with "elbow ulnar collateral ligament injury" or "tommy john injury" (P ≤ .001). Magnetic resonance imaging (MRI) is an excellent tool for the evaluation of joint pathology due to its high sensitivity as a result of high contrast resolution for soft tissues. Further work is needed before definitive guidelines for olecranon osteotomy can be formulated. Recent advances in both nonoperative and operative treatment, including arthroscopic techniques, have afforded the athlete a successful return to competition. The large percentage of excellent and good results in patients who have had correction of mechanical disorders of the elbow has been encouraging. Website quality was further assessed by the Journal of the American Medical Association benchmark criteria and Health on the Net Foundation certification. After checking osteophyte size and location through 3-dimensional computed tomography, arthroscopic osteophyte resection was performed. Specifically, baseball pitchers are at high risk due to repetitive valgus elbow strain while throwing baseballs at a high velocity. To assess the return to play and in-game performance specific to baseball pitchers who have undergone primary UCLR. applying a valgus stress to the elbow. Because tendinopathy, tendonitis, and tendon tears have an anatomic basis for their pathology, a targeted history and meticulous physical examination often yields an accurate clinical diagnosis. Valgus extension overload in the pitching elbow. Some interpretations of the outcomes of some orthopedic surgeries have been stimulating the belief that it may enhance athletes to higher levels of performance. Characteristic factors and presurgery performance statistics were compared between poor performers (>20% decrease in fastball accuracy) and non—poor performers. The patients with posteromedial olecranon osteophytes had the highest rate of reoperation, and patients who underwent ulnar collateral ligament reconstruction had a higher rate of return to play. Methods This article aims to describe the normal imaging anatomy and biomechanics of the elbow, the most commonly used MRI protocols and techniques, and common MRI findings related to tendinopathy, ligamentous and osteochondral injuries, and instability of the elbow. In this article, we review indications and surgical setup for elbow arthroscopy. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. Reduced elbow valgus torques were associated with increased elbow flexion (P < .01). Results: Published by Elsevier Inc. All rights reserved. VEO is characterized by repro … Overuse injuries of the shoulder and elbow are common in the skeletally immature throwing athlete. Treatment of VEO syndrome initiates with conservative measures like active rest, physiotherapy, and non-steroid anti-inflammatory medication but may require arthroscopy with osteophyte removal and medial corner olecranon osteotomy in refractory cases. Twenty-seven patients with recalcitrant lateral epicondylitis who had failed conservative therapy and who had no previous trauma or overt instability, were included. Case description: Conclusions In contrast, bone marrow edema and associated soft tissue injuries in PMOI are more readily observed on MRI. valgus extension overload. ... Sports injuries are a common cause of ulnar nerve entrapment (Tables 38.1 and 38.2). Impairments at evaluation included proximal stabilizing strength deficits, myofascial trigger points throughout the dominant upper extremity, improper pitching form, and inability to pitch in game conditions due to severe pain. Results The combination of valgus and extension overload during overhead activities results in tensile forces along the medial stabilising structures, with … Fastball accuracy among MLB pitchers significantly decreased after UCL reconstruction for up to 3 years postoperatively. Athletes with UCL injury complain of acute or chronic medial elbow injury, resulting in decreased throwing effectiveness, with loss of control and/or velocity. If conservative management including rest, nonsteroidal anti-inflammatory drugs, and steroid injections fail, arthroscopic evaluation with debridement and resection of the posteromedial olecranon osteophytes may be performed. Am J Sports Med 1983; Outcome of Elbow Surgery in Professional Baseball Players, Bony Injuries Of The Wrist, Forearm, And Elbow, Arthroscopy of the elbow: A long-term clinical review, Relationship of Ulnar Collateral Ligament Strain to Amount of Medial Olecranon Osteotomy, Posterior olecranon resection and ulnar collateral ligament strain, Elbow injuries in the throwing athlete. The most common diagnosis was posterior impingement in 96 patients (51%), followed by loose bodies in 72 patients (31%), and degenerative joint disease in 32 patients (22%). Sites certified by the Health on the Net Foundation had higher quality scores than non-certified sites (P = .034). Systematic review. Ulnar collateral ligament injuries, snapping triceps, medial epicondylitis, and ulnar nerve pathology are presented with key features of clinical exam, diagnostic tests, and current aspects of treatment. Despite an increase in the prevalence of medial ulnar collateral ligament (UCL) reconstruction of the elbow in professional baseball and popularity within the media, there are no population-based studies examining the incidence of UCL reconstruction. A thorough patient history and physical examination with appropriate diagnostic imaging is required to correctly identify the etiology of the elbow pain. CT was superior to MRI with a statistically significant (P<0.05) difference in detecting joint space narrowing, medial olecranon subluxation, as well as the number of loose bodies. Studies have shown that various biomechanical factors affect valgus extension overload during baseball pitching; yet, their relationships are not clearly defined, and factors such as trunk rotation and arm slot have not been investigated. Noch schwieriger scheint es, die zum Beschwerdebild beitragenden Faktoren zu erkennen und in die Therapie miteinzubeziehen. Basic science studies have improved our understanding of the pathomechanics for valgus extension overload and olecranon stress fractures. Summary Posterior elbow pain in sportsmen is connected with different pathologies, related to the age and to the kind of sports. Methods: (1) Faulty mechanics developed at young ages are often well-engrained by the late adolescent years and the minimal healing ability of the largely avascular UCL often leads to delayed safe return to sport.(2). The quality of medical information on the Internet has come under scrutiny. Level of evidenceIII. Furthermore, the presence or absence of ulnar collateral ligament (UCL) injuries and avulsion fractures of the lower pole of the medial epicondyle was determined by imaging findings to calculate the combined percentage of OSFs. Eligibility criteria Since several etiologies may coexist, the emphasis on correct diagnostic strategies is provided. Results: These osteophytes frequently lead to pain and dysfunction during the acceleration phase of throwing and release of the ball. There were no statistically significant differences in characteristic factors or presurgery performance statistics between poor and non--poor performers. When Is It Too Early for Single Sport Specialization? Injury to the ulnar collateral ligament (UCL) often results in valgus elbow instability requiring reconstruction. Single-assessment numeric evaluation (SANE), Oxford Elbow Score (OES), quickDASH (Disabilities of the Arm, Shoulder, Hand), patient satisfaction and post-operative range of motion were evaluated. Athletes at risk for valgus extension overload are also at risk for tears of the anterior bundle of the ulnar collateral ligament. Background: The condition is caused by a repetitive valgus force and medial laxity of the elbow leading to excessive shear forces and compression of the articulation between the posteromedial olecranon and the olecranon fossa (Fig. Valgus extension overload: diagnosis and treatment. The procedures were performed primarily by 7 different surgeons, using all 3 standard operating positions and a variety of arthroscopic portals. If the UCL or dynamic flexorpronator musculature is incompetent, elbow extension and valgus torque, as seen in throwing, can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation. All studies were of level 3 or 4 evidence, and the mean ± SD MINORS score was 14.4 ± 3.0, which indicates fair quality of evidence for nonrandomized studies. First-line treatment for VEO is After exclusion for lack of return to play (n = 14) and revision surgery (n = 3), 39 pitchers were included in the final analysis. The biomechanical findings of this study offer scientific feedback for developing methods used to minimize the effects of valgus load on pitching-related elbow injuries. However, most studies showed that UCLR was associated with a prolonged recovery and significant decline in pitching performance as objectively measured by in-game statistics. A repeated-measures analysis of variance with a Tukey-Kramer post hoc test was used to determine statistically significant changes in performance over time. Despite the increased incidence of UCL reconstruction, the rate of revision UCL reconstruction surgery has decreased, likely secondary to improved surgical techniques and rehabilitation protocols. Valgus extension overload (VEO) is a condition observed in overhead athletes that results from laxity of the ulnar collateral ligament (UCL). The New York Statewide Planning and Research Cooperative System (SPARCS) database contains records for each ambulatory discharge in New York State. Posterior elbow pain is a common problem in the throwing athlete due to adaptive bony and soft tissue changes in response to valgus extension overload (VEO) syndrome. Website readability was ascertained with the Flesch-Kincaid score. The shoulder complex is a crucial component of the upper body kinetic chain as it transmits force created in the lower body to the arm and hand to produce velocity and accuracy with ball release. The mean reading grade level was 10.7. With a more detailed knowledge of the injury mechanisms and up-to-date treatment options for these patients, physicians will be able to prevent and better treat medial elbow pain in overhead athletes. Accurate diagnosis and proper treatment of elbow injuries in the throwing athlete requires a thorough understanding of elbow function and anatomy, as well as an understanding of throwing mechanics and pathomechanics. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of Arm, Shoulder and Hand (DASH), Numeric Pain Report Scale (NPRS), and return to sport. Over the past 15 years, there has been an increase in youth sports participation with a concomitant increase in early year-round training in a single sport. However, the "weekend warrior" can sustain similar injuries and can have a similar desire to return to play as quickly as possible. The minimal follow-up was 6 months and the maximum was 4 years, for a mean of 2.3 years. We dissected and mounted five fresh-frozen human cadaveric elbows to allow strain gauge monitoring of the ulnar collateral ligament with varying valgus stress, elbow flexion angle, and medial osteotomy. However, if just this posterior osteophyte is removed, the described lesion will be missed, with resultant persistent disability. The main objective of the present paper is to investigate if some orthopedic surgeries may be associated to doping effect and performance enhancement, with special attention to the baseball reality. Olecranon stress fractures are rare, but can cause significant discomfort and, if unrecognized or untreated, can lead to significant pain and dysfunction. Am J Orthop 2016;45:144-151. Objective A 2-way analysis of variance compared valgus torques between pitchers with 2 onsets of trunk rotation (before and after front-foot contact) and 2 arm slot positions (overhand and sidearm). The average strain to failure was 11.96%+/-6.51%, corresponding to a load of 347.71+/-46.42 N. The maximum tensile force recorded at failure was 416.24 N. Three-way repeated-measures analysis of variance revealed no significant change in strain with change in the amount of osteotomy for a given applied load and angle of flexion. It is not known how much of the posterior olecranon can be resected before increased stress is placed on the ulnar collateral ligament. ... As many as 10% to 25% of active MLB pitchers report a history of UCL reconstruction, and there has been an estimated 10-fold increase in cases among professional players since 2000. Intraarticular loose bodies were found in 39% of the patients. There was a high rate of return to pitching after UCLR. The amount of olecranon tip that can safely be resected without placing additional stress on the UCL is thought to be less than 3 mm. CT is superior in identifying some imaging features of PMOI. As a result, radiologists will increasingly be asked to evaluate elbow imaging of patients presenting with pain who have had UCL reconstruction. Forty-three websites (38.1%) described surgical reconstruction; of these, 16 (37.2%) mentioned improved pitching performance postoperatively. Imaging can provide additional information when the clinical picture is unclear or further information is necessary for risk stratification and treatment planning. Specifically, baseball pitchers who underwent elbow ulnar colateral ligament reconstruction, after its rupture, could be able to throw with higher intensity in comparison to athletes with the non injured native ligament. When mandated by the presence of a loose body or areas of cartilage wear in the anterior compartment, especially medially, a … The physeal type was further separated into stages 1 to 4 based on severity. The following chapter provides an overview of the relevant anatomy, biomechanics, and diagnosis of VEO. High energy and can be quite disabling to the high repetitive stresses generated the! 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