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Valgus Extension Overload

  • Valgus extension overload is a condition characterized by posteromedial elbow pain related to repetitive microtrauma in throwing athletes
  • Repetitive stress through the throwing motion leads to excessive shear forces on the medial aspect of the olecranon tip/olecranon fossa and lateral compressive forces which can lead to:
    • Cartilage loss across the olecranon or olecranon fossa
    • Osteochondral lesions of the capitellum
    • Posteromedial osteophytes with loose bodies
    • UCL attenuation

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  • Athletes typically present with posteromedial elbow pain in full elbow extension
    • Most common in the deceleration/follow-through phase of throwing
    • Physical exam may have crepitus secondary to loose bodies, pain with “arm bar test” (forced elbow extension) or “bounce test” (repetitive terminal elbow extension)
    • Throwers may have loss of terminal extension and tenderness over the posteromedial olecranon
    • Athletes who have “fractured” through a posterior osteophyte may present with an acutely swollen, painful elbow and limited range of motion

Dr. Nelson performing “arm bar test” and “bounce test” for posterior elbow pain


  • Radiographs frequently demonstrate osteophyte formation in the posteromedial olecranon
  • CT scan is best for identifying loose bodies and osteophytes for surgical planning
  • MRI is useful to rule out associated injuries such as UCL tears

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X-ray demonstrating Osteophytes within the olecranon fossa

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CT scan demonstrates posteromedial osteophytes within the olecranon fossa



  • First-time symptomatic patients or athletes mid-season may benefit from a period of rest and anti-inflammatories with gradual return to throwing while focusing on proper throwing mechanics. Occasionally steroid injections can be a useful adjunct.


  • Arthroscopic resection of osteophytes and removal of loose bodies is indicated for throwing athletes who have failed to improve or have ongoing mechanical symptoms
  • Care must be taken to only remove posteromedial osteophytes and avoid over-resection as this can lead to increased stress on the ulnar collateral ligament resulting in valgus instability

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