Valgus Extension Overload Syndrome and Olecranon Stress Fractures

Tremendous forces regulated by the elbow during throwing challenge the olecranon putting it at risk for valgus extension overload injuries and olecranon stress fractures. The pathomechanics for these two injuries are similar and include repetitive abutment of the olecranon into the olecranon fossa combined with valgus torques resulting in impaction and shear along the posteromedial olecranon. When the bone and cartilage is overwhelmed, either posteromedial osteophytes and loose bodies develop, or stress fracture occurs. Identifying the location of pain and timing during the pitching phase helps differentiate the 2 injuries. In each disorder, physical examination may demonstrate motion loss, crepitus, and tenderness at the posteromedial olecranon. In valgus extension overload, posteromedial osteophytes and loose bodies within the articulation may be identified on radiographs, computed tomography, or MRI. For stress fractures, radiographs typically show a fracture line with sclerosis, although a bone scan or MRI may be necessary in questionable cases. For valgus extension overload, if initial nonoperative treatment fails, arthroscopic debridement or limited incision arthrotomy to decompress the posterior compartment is indicated. The status of the medial collateral ligament must be accurately assessed and managed because medial collateral ligament insufficiency is often a factor in the development of valgus extension overload. Stress fractures that fail conservative management may be treated with internal fixation and if indicated, bone grafting.