The Thrower's Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome


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. It has been considered separately from other athletic injuries due to the unique constellation of pathology that results from repetitive overhead throwing. The past decade has witnessed tremendous gains in understanding of the complex interplay between the dynamic and static stabilizers of the athlete's elbow. Likewise, the necessity to treat these problems in a minimally invasive manner has driven the development of sophisticated techniques and instrumentation for elbow arthroscopy.

MCL injuries, ulnar neuritis, valgus extension overload with osteophyte formation and posteromedial impingement, flexor pronator strain, medial epicondyle pathology, and osteochondritis dissecans (OCD) of the capitellum have all been described as sequelae of the overhead throwing motion. In addition, loose body formation, bony spur formation, and capsular contracture can all be present in conjunction with these problems or as isolated entities. Not all pathology in the thrower's elbow is amenable to arthroscopic treatment; however, the clinician must be familiar with all of these problems in order to form a comprehensive differential diagnosis for an athlete presenting with elbow pain, and he or she must be comfortable with the variety of open and arthroscopic treatments available to best serve the patient.

An understanding of the anatomy and biomechanics of the thrower's elbow is critical to the care of this population. The preoperative evaluation should focus on a thorough history and physical examination, as wellas on specific diagnostic imaging modalities. Arthroscopic setup, including anesthesia, patient positioning, and portal choices will be discussed. Operative techniques in the anterior and posterior compartments will bereviewed, as well as postoperative rehabilitationandsurgical results. Lastly, complications will be reviewed.

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  1. 1.

    A Chen T Youm B Ong et al. (2003) ArticleTitleImaging of the elbow in the overhead throwing athlete Am J Sports Med 31 466–473 Occurrence Handle12750146

    PubMed  Google Scholar 

  2. 2.

    E Cain J Dugas R Wolf J Andrews (2003) ArticleTitleElbow injuries in throwing athletes: a current concepts review Am J Sports Med 31 621–635 Occurrence Handle12860556

    PubMed  Google Scholar 

  3. 3.

    M Schickendantz (2002) ArticleTitleDiagnosis and treatment of elbow disorders in the overhead athlete Hand Clin 18 65–75 Occurrence Handle10.1016/S0749-0712(02)00007-0 Occurrence Handle12143419

    Article  PubMed  Google Scholar 

  4. 4.

    C Ball L Galatz K Yamaguchi (2002) ArticleTitleElbow instability: treatment strategies and emerging concepts Instr Course Lect 51 53–61 Occurrence Handle12064144

    PubMed  Google Scholar 

  5. 5.

    L Rizio J Uribe (2001) ArticleTitleOveruse injuries of the upper extremity in baseball Clin Sports Med 20 IssueID3 453–468 Occurrence Handle10.1016/S0278-5919(05)70262-3 Occurrence Handle1:STN:280:DC%2BD3MvkvFKrsg%3D%3D Occurrence Handle11494834

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    C Miller F Savoie SuffixIII (1994 Oct) ArticleTitleValgus extension injuries of the elbow in the throwing athlete J Am Acad Orthop Surg 2 IssueID5 261–269

    Google Scholar 

  7. 7.

    F Chen A Rokito F Jobe (2001 Mar–Apr) ArticleTitleMedial elbow problems in the overhead throwing athlete J Am Acad Orthop Surg 9 IssueID2 99–113 Occurrence Handle1:STN:280:DC%2BD3MzisVGruw%3D%3D

    CAS  Google Scholar 

  8. 8.

    BF Morrey KN An (1983) ArticleTitleArticular and ligamentous contributions to the stability of the elbow joint Am J Sports Med 11 315–319 Occurrence Handle1:STN:280:BiuD2cbosFQ%3D Occurrence Handle6638246

    CAS  PubMed  Google Scholar 

  9. 9.

    BF Morrey (1986) ArticleTitleApplied anatomy and biomechanics of the elbow joint Instr Course Lect 35 59–68 Occurrence Handle1:STN:280:BiiC3sbivVE%3D Occurrence Handle3819430

    CAS  PubMed  Google Scholar 

  10. 10.

    BF Morrey KN An (1985) ArticleTitleFunctional anatomy of the ligaments of the elbow Clin Orthop 201 84–90 Occurrence Handle4064425

    PubMed  Google Scholar 

  11. 11.

    CJ Dillman GS Fleisig JR Andrews (1993) ArticleTitleBiomechanics of pitching with emphasis upon shoulder kinematics J Orthop Sports Phys Ther 18 402–408 Occurrence Handle1:STN:280:ByyA2s3ovVQ%3D Occurrence Handle8364594

    CAS  PubMed  Google Scholar 

  12. 12.

    GS Fleisig JR Andrews CJ Dillman et al. (1995) ArticleTitleKinetics of baseball pitching with implications about injury mechanisms Am J Sports Med 23 233–239 Occurrence Handle1:STN:280:ByqB1Mjmt1c%3D Occurrence Handle7778711

    CAS  PubMed  Google Scholar 

  13. 13.

    A Pappas R Zawacki T Sullivan (1985) ArticleTitleBiomechanics of baseball pitching: a preliminary report Am J Sports Med 13 216–222 Occurrence Handle1:STN:280:BiqB2snovF0%3D Occurrence Handle4025673

    CAS  PubMed  Google Scholar 

  14. 14.

    FD Wilson JR Andrews TA Blackburn et al. (1983) ArticleTitleValgus extension overload in the pitching elbow Am J Sports Med 11 83–88 Occurrence Handle1:STN:280:BiyB3c7nvVc%3D Occurrence Handle6846685

    CAS  PubMed  Google Scholar 

  15. 15.

    JE Conway FW Jobe RE Glousman et al. (1992) ArticleTitleMedial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament J Bone Jt Surg 74A 67–83

    Google Scholar 

  16. 16.

    O'Driscoll S, Savoie F: Arthroscopy of the elbow, in ...

  17. 17.

    JW King HJ Brelsford HS Tullos (1969) ArticleTitleAnalysis of the pitching arm of the professional baseball pitcher Clin Orthop 67 116–123 Occurrence Handle1:STN:280:CS%2BD28ros1c%3D Occurrence Handle5361189

    CAS  PubMed  Google Scholar 

  18. 18.

    LA Timmerman ML Schwartz JR Andrews (1994) ArticleTitlePreoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation Am J Sports Med 22 26–32 Occurrence Handle1:STN:280:ByuC2sritlI%3D Occurrence Handle8129106

    CAS  PubMed  Google Scholar 

  19. 19.

    HG Potter (2000) ArticleTitleImaging of posttraumatic and soft tissue dysfunction of the elbow Clin Orthop 370 9–18 Occurrence Handle10660698

    PubMed  Google Scholar 

  20. 20.

    EA Gaary HG Potter DW Altchek (1997) ArticleTitleMedial elbow pain in the throwing athlete: MR imaging evaluation AJR Am J Roentgenol 168 795–800 Occurrence Handle1:STN:280:ByiB3M%2Fks1A%3D Occurrence Handle9057537

    CAS  PubMed  Google Scholar 

  21. 21.

    HG Potter ST Ho DW Altchek (2004 Mar) ArticleTitleMagnetic resonance imaging of the elbow Semin Musculoskelet Radiol 8 IssueID1 5–16

    Google Scholar 

  22. 22.

    HG Potter JM Linklater AA Allen JA Hannafin SB Haas (1998 Sep) ArticleTitleMagnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging J Bone Jt Surg Am 80 IssueID9 1276–1284 Occurrence Handle1:STN:280:DyaK1cvjtVKisw%3D%3D

    CAS  Google Scholar 

  23. 23.

    JT Rohrbough DW Altchek J Hyman RJ Williams SuffixIII JD Botts (2002 Jul–Aug) ArticleTitleMedial collateral ligament reconstruction of the elbow using the docking technique Am J Sports Med 30 IssueID4 541–548

    Google Scholar 

  24. 24.

    LD Field DW Altchek (1996) ArticleTitleEvaluation of the arthroscopic valgus instability test of the elbow Am J Sports Med 24 177–181 Occurrence Handle1:STN:280:BymA2s7ivVU%3D Occurrence Handle8775116

    CAS  PubMed  Google Scholar 

  25. 25.

    JB Jupiter SW O'Driscoll MS Cohen (2003) ArticleTitleThe assessment and management of the stiff elbow Instr Course Lect 52 93–111 Occurrence Handle12690843

    PubMed  Google Scholar 

  26. 26.

    CM Ball M Meunier LM Galatz R Calfee K Yamaguchi (2002 Nov–Dec) ArticleTitleArthroscopic treatment of post-traumatic elbow contracture J Should Elb Surg 11 IssueID6 624–629

    Google Scholar 

  27. 27.

    BB Phillips S Strasburger (1998 Jan–Feb) ArticleTitleArthroscopic treatment of arthrofibrosis of the elbow joint Arthroscopy 14 IssueID1 38–44 Occurrence Handle1:STN:280:DyaK1c7kslartw%3D%3D

    CAS  Google Scholar 

  28. 28.

    SJ Kim HK Kim JW Lee (1995 Dec) ArticleTitleArthroscopy for limitation of motion of the elbow Arthroscopy 11 IssueID6 680–683 Occurrence Handle1:STN:280:BymB1MnnvVQ%3D

    CAS  Google Scholar 

  29. 29.

    T Haapaniemi M Berggren L Adolfsson (1999 Oct) ArticleTitleComplete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture Arthroscopy 15 IssueID7 784–787 Occurrence Handle1:STN:280:DyaK1Mvlt1ClsA%3D%3D

    CAS  Google Scholar 

  30. 30.

    JR Andrews WG Carson (1985) ArticleTitleArthroscopy of the elbow Arthroscopy 1 97–107 Occurrence Handle1:STN:280:BimC3s%2FpslQ%3D Occurrence Handle4091924

    CAS  PubMed  Google Scholar 

  31. 31.

    GD Walcott FH Savoie LD Field (2001) Arthroscopy of the elbow: setup, portals, and diagnostic technique DW Altchek JR Andrews (Eds) The athlete's elbow Lippincott, Williams & Wilkins Philadelphia, PA 209–217

    Google Scholar 

  32. 32.

    GG Poehling TL Whipple L Sisco et al. (1989) ArticleTitleElbow arthroscopy: a new technique Arthroscopy 5 222–224 Occurrence Handle1:STN:280:BiaA2svktlM%3D Occurrence Handle2775398

    CAS  PubMed  Google Scholar 

  33. 33.

    DW Altchek J Hyman R Williams et al. (2000) ArticleTitleManagement of MCL injuries of the elbow in throwers Tech Should Elb Surg 1 IssueID2 73–81

    Google Scholar 

  34. 34.

    K Stothers BD Day WR Regan (1995) ArticleTitleArthroscopy of the elbow: anatomy, portal sites, and a description of the proximal lateral portal Arthroscopy 11 IssueID4 449–457 Occurrence Handle1:STN:280:BymD3snhsFM%3D Occurrence Handle7575879

    CAS  PubMed  Google Scholar 

  35. 35.

    L Adolfsson (1994) ArticleTitleArthroscopy of the elbow joint: a cadaveric study of portal placement J Should Elb Surg 3 53–61

    Google Scholar 

  36. 36.

    LD Field DW Altchek RF Warren (1994) ArticleTitleArthroscopic anatomy of the lateral elbow: a comparison of three portals Arthroscopy 10 602–607 Occurrence Handle1:STN:280:ByqC1crps1U%3D Occurrence Handle7880349

    CAS  PubMed  Google Scholar 

  37. 37.

    JD Papilion RS Neff LM Shall (1988) ArticleTitleCompression neuropathy of the radial nerve as a complication of elbow arthroscopy: a case report and review of the literature Arthroscopy 4 284–286 Occurrence Handle1:STN:280:BiaC28rpsVc%3D Occurrence Handle2852940

    CAS  PubMed  Google Scholar 

  38. 38.

    DS Ruch GG Poehling (1997) ArticleTitleAnterior interosseous nerve injury following elbow arthroscopy Arthroscopy 13 756–758 Occurrence Handle1:STN:280:DyaK1c7gsVCitg%3D%3D Occurrence Handle9442332

    CAS  PubMed  Google Scholar 

  39. 39.

    MA Thomas A Fast D Shapiro (1987) ArticleTitleRadial Nerve damage asa complication of elbow arthroscopy Clin Orthop 215 130–131 Occurrence Handle3802628

    PubMed  Google Scholar 

  40. 40.

    AS Reddy RS Kvitne LA Yocum NS Elattrache RE Glousman FW Jobe (2000 Sep) ArticleTitleArthroscopy of the elbow: a long-term clinical review Arthroscopy 16 IssueID6 588–594 Occurrence Handle1:STN:280:DC%2BD3cvlslSqug%3D%3D

    CAS  Google Scholar 

  41. 41.

    SW O'Driscoll BF Morrey (1992 Jan) ArticleTitleArthroscopy of the elbow. Diagnostic and therapeutic benefits and hazards J Bone Jt Surg Am 74 IssueID1 84–94

    Google Scholar 

  42. 42.

    JR Andrews WG Carson (1985) ArticleTitleArthroscopy of the elbow Arthroscopy 1 IssueID2 97–107 Occurrence Handle1:STN:280:BimC3s%2FpslQ%3D Occurrence Handle4091924

    CAS  PubMed  Google Scholar 

  43. 43.

    Morrey BF. Complications of elbow arthroscopy. In...pp. 519–522.

  44. 44.

    SJ Kim SJ Shin (2000 Jun) ArticleTitleArthroscopic treatment for limitation of motion of the elbow Clin Orthop 375 140–148

    Google Scholar 

  45. 45.

    TR Kuklo KF Taylor KP Murphy et al. (1999) ArticleTitleArthroscopic release for lateral epicondylitis: a cadaver model Arthroscopy 15 259–264 Occurrence Handle1:STN:280:DyaK1M3ks1WgsQ%3D%3D Occurrence Handle10231102

    CAS  PubMed  Google Scholar 

  46. 46.

    BD Owens KP Murphy TR Kuklo (2001) ArticleTitleArthroscopic release for lateral epicondylitis Arthroscopy 17 582–587 Occurrence Handle1:STN:280:DC%2BD38%2FitFCntQ%3D%3D Occurrence Handle11447544

    CAS  PubMed  Google Scholar 

  47. 47.

    MR Krijnen L Lim WJ Willems (2003) ArticleTitleArthroscopic treatment of osteochondritis dissecans of the capitellum: report of 5 female athletes Arthroscopy 19 210–214 Occurrence Handle12579155

    PubMed  Google Scholar 

  48. 48.

    S Kamineni H Hirahara S Pomianowski PG Neale SW O'Driscoll N ElAttrache KN An BF Morrey (2003 Jun) ArticleTitlePartial posteromedial olecranon resection: a kinematic study J Bone Jt Surg Am 85-A IssueID6 1005–1011 Occurrence Handle1:STN:280:DC%2BD3s3lvVKntQ%3D%3D

    CAS  Google Scholar 

  49. 49.

    S Kamineni NS El:Attrache SW O'Driscoll CS Ahmad H Hirohara PG Neale KN An BF Morrey (2004 Nov) ArticleTitleMedial collateral ligament strain with partial posteromedial olecranon resection. A biomechanical study J Bone Jt Surg Am 86-A IssueID11 2424–2430

    Google Scholar 

  50. 50.

    JR Andrews LA Timmerman (1995) ArticleTitleOutcome of elbow surgery in professional baseball players Am J Sports Med 23 IssueID4 407–413 Occurrence Handle1:STN:280:BymD2c%2Fkt1w%3D Occurrence Handle7573648

    CAS  PubMed  Google Scholar 

  51. 51.

    KE Wilk M Levinson (2001) Rehabilitation of the athlete's elbow DW Altchek JR Andrews (Eds) The athlete's elbow Lippincott, Williams & Wilkins Philadelphia, PA 249–273

    Google Scholar 

  52. 52.

    O'Holleran JD, Altchek DW (2005) Elbow arthroscopy: treatment of the thrower's elbow. Instr Course Lect 55, in press.

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Correspondence to James D. O'Holleran MD.

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O'Holleran, J.D., Altchek, D.W. The Thrower's Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome. HSS Jrnl 2, 83–93 (2006).

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  • Ulnar Nerve
  • Medial Collateral Ligament
  • Loose Body
  • Capsular Contracture
  • Osteochondritis Dissecans