Valgus Extension Overload Syndrome (VEOS)

with Rehab

Valgus extension overload syndrome (VEOS) is a group of problems and pains within the elbow due to overuse and repetitive throwing forces. The ulnar collateral ligament (UCL) on the inner side of the elbow is a structure that helps keep the normal relationship of the arm bone (humerus) and the one of the forearm bones (ulna). This ligament may be stretched over time with repeated hard throwing. The stretching of the ligament results in gapping of the inner side of the elbow. This stretches the ulnar nerve on the inner elbow, causing symptoms in the hand, particularly the ring and little fingers. The outer part of the elbow and the back of the elbow develop increased pressure from the loose UCL, resulting in cartilage injury, bone spurs and loose pieces of bone floating within the elbow joint.

SYMPTOMS

  • Pain and tenderness around the elbow (inner, outer or back of the elbow), especially when trying to throw or straighten the elbow.

  • Occasional locking or catching of the elbow.

  • Swelling of the elbow.

  • Inability to throw at full speed and loss of ball control.

  • Elbow stiffness; inability to straighten the elbow.

  • Numbness or tingling in the ring and little fingers.

  • Clumsiness and weak hand grip.

CAUSES

Force that exceeds the strength of the ligament results in stretching of the ulnar collateral ligament of the elbow. This injury usually is the result of throwing repetitively or particularly hard, which produces stretching of the ulnar nerve and increased pressure of the cartilage on the outer portion of the elbow, as well as the back of the elbow. This causes bone spurs to form, which may break off and become loose pieces of bone within the joint.

RISK INCREASES WITH:

  • Sports in which the arm is used to throw or the arm is straightened hard (baseball, javelin, hockey, tennis, volleyball).

  • Poor physical conditioning (strength and flexibility).

  • Improper throwing mechanics.

  • Sports in which there is a valgus force on an extended elbow (gymnastics) or hyper extension of the elbow (boxing, weightlifting).

PREVENTION

  • Appropriate warm up and stretchs before practice and competition.

  • Maintain appropriate conditioning:

  • Arm, forearm, and wrist flexibility.

  • Muscle strength and endurance.

  • Use proper technique when throwing, serving or hitting.

  • Braces may be effective in preventing injury, especially re-injury, by reducing forceful straightening of the elbow.

PROGNOSIS

Often this condition is treatable with non-operative management, although surgery may be required to alleviate symptoms. Persons with VEOS are prone to recurrence after a prolonged period if the sport is continued.

RELATED COMPLICATIONS

  • Frequent recurrence of symptoms and repeated injury, resulting in a chronic problem, such as inability to throw at full speed or distance, pain with throwing and loss of ball control, especially if activity is resumed too soon after injury. Appropriately addressing the problem the first time decreases frequency of recurrence and optimizes healing time.

  • Prolonged healing time if activities are resumed too soon.

  • Injury to other structures of the elbow, including medial epicondylitis, and strain of the muscle-tendon of the muscles that bend the wrist.

  • Arthritis of the elbow.

  • Elbow stiffness (loss of elbow motion).

  • Locking of the elbow.

  • Prolonged disability.

  • Inability to return to the same level of sports.

  • Tear of the ulnar collateral ligament.

  • Risks of surgery, including infection, bleeding, injury to nerves, persistent pain, increased pain, catching or locking, tearing and need for further surgery.

TREATMENT

Initial treatment consists of medication and ice to relieve the pain and modification of the activity that initially caused the problem. Occasionally a splint, brace, or cast may be recommended. Elbow range-of-motion, strength and endurance exercises should be done. Use proper throwing mechanics. These may be carried out at home, although usually referral to a physical therapist or athletic trainer is recommended. A gradual return to throwing is attempted. If symptoms persist or if there is locking and catching, which are due to loose bone fragments within the joint, arthroscopic surgery is recommended. Surgery is performed to remove bone spurs, bone fragments, and loose cartilage. Return to sports after surgery may take 3 months.

MEDICATION

  • Nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take for 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your caregiver. Contact your caregiver immediately if any bleeding, stomach upset or signs of an allergic reaction occur.

  • Stronger pain relievers may be prescribed as necessary by your caregiver. Use only as directed.

COLD THERAPY

Cold is used to relieve pain and reduce inflammation. Cold should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or massage the area with a piece of ice (ice massage).

SEEK MEDICAL CARE IF:

  • Symptoms get worse or do not improve in 4 to 6 weeks despite treatment.

  • You experience pain, numbness or coldness in the hand.

  • A blue, gray or dark color appears in your fingernails.

  • New, unexplained symptoms develop (drugs used in treatment may produce side effects).

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Valgus Extension Overload Syndrome (VEOS)

These exercises may help you restore your elbow mobility once your physician has discontinued your immobilization period. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

RANGE OF MOTION – Supination, Active-Assisted

  • Sit with your right / left elbow bent 90 degrees and rest your forearm on a table.

  • Keeping your upper body and shoulder in place, roll your forearm so your palm faces upward. When you can go no farther, use your opposite hand to help until you feel a gentle to moderate stretch. Hold for __________ seconds.

  • Slowly release the stretch and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION – Pronation, Active-Assisted

  • Sit with your right / left elbow bent 90 degrees and rest your forearm on a table.

  • Keeping your upper body and shoulder in place, roll your forearm so your palm faces the tabletop. When you can go no farther, use your opposite hand to help until you feel a gentle to moderate stretch. Hold for __________ seconds.

  • Slowly release the stretch and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION – Extension

  • Hold your right / left arm at your side and straighten your elbow as far as you can using your right / left arm muscles.

  • Straighten the right / left elbow farther by gently pushing down on your forearm until you feel a gentle stretch on the inside of your elbow. Hold this position for __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION – Flexion

  • Hold your right / left arm at your side and bend your elbow as far as you can using your right / left arm muscles.

  • Bend the right / left elbow farther by gently pushing up on your forearm until you feel a gentle stretch on the outside of your elbow. Hold this position for __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION – Elbow Flexion, Supine

  • Lie on your back. Extend your right / left arm into the air, bracing it with your opposite hand. Allow your right / left arm to relax.

  • Let your elbow bend, allowing your hand to fall slowly toward your chest.

  • You should feel a gentle stretch along the back of your upper arm and/or elbow. Your physician, physical therapist or athletic trainer may ask you to hold a __________ hand weight to increase the intensity of this stretch.

  • Hold for __________ seconds. Slowly return your right / left arm to the upright position.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH – Elbow Flexors

  • Lie on your back on a firm surface. Be sure that you are in a comfortable position which will allow you to relax your arm muscles.

  • Place a folded towel under your upper arm so that your elbow and shoulder are at the same height. Extend your arm; your elbow should not rest on the bed or towel.

  • Allow the weight of your hand to straighten your elbow. Keep your arm and chest muscles relaxed. Your clinician may ask you to increase the intensity of your stretch by adding a small wrist or hand weight.

  • Hold for __________ seconds. You should feel a stretch on the inside of your elbow. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTHENING EXERCISES - Valgus Extension Overload Syndrome (VEOS)

These exercises may help you regain your strength after your physician has discontinued your immobilization in a cast or brace. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress with the resistance and repetition exercises only as your caregiver advises.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

STRENGTH – Elbow Flexors, Supinated

  • With good posture, stand or sit on a firm chair without armrests. Allow your right / left arm to rest at your side with your palm facing forward.

  • Holding a __________ weight or gripping a rubber exercise band/tubing, bring your hand toward your shoulder.

  • Allow your muscles to control the resistance as your hand returns to your side.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Elbow Flexors, Neutral

  • With good posture, stand or sit on a firm chair without armrests. Allow your right / left arm to rest at your side with your thumb facing forward.

  • Holding a __________ weight or gripping a rubber exercise band/tubing, bring your hand toward your shoulder.

  • Allow your muscles to control the resistance as your hand returns to your side.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Elbow Extensors

  • Lie on your back. Extend your right / left elbow into the air, pointing it toward the ceiling. Brace your arm with your opposite hand.*

  • Holding a __________ weight in your hand, slowly straighten your right / left elbow.

  • Allow your muscles to control the weight as your hand returns to its starting position.

Repeat __________ times. Complete this exercise __________ times per day.

*You may also stand with your elbow overhead and pointed toward the ceiling and supported by your opposite hand.

STRENGTH - Elbow Extensors, Dynamic

  • With good posture, stand or sit on a firm chair without armrests. Keeping your upper arms at your side, bring both hands up to your right / left shoulder while gripping a rubber exercise band/tubing. Your right / left hand should be just below the other hand.

  • Straighten your right / left elbow. Hold for __________ seconds.

  • Allow your muscles to control the rubber exercise band/tubing as your hand returns to your shoulder.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Wrist Flexors

  • Sit with your right / left forearm palm-up and fully supported. Your elbow should be resting below the height of your shoulder. Allow your wrist to extend over the edge of the surface.

  • Loosely holding a __________ weight or a piece of rubber exercise band/tubing, slowly curl your hand up toward your forearm.

  • Hold this position for __________ seconds. Slowly lower the wrist back to the starting position in a controlled manner.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Wrist Extensors

  • Sit with your right / left forearm palm-down and fully supported. Your elbow should be resting below the height of your shoulder. Allow your wrist to extend over the edge of the surface.

  • Loosely holding a __________ weight or a piece of rubber exercise band/tubing, slowly curl your hand up toward your forearm.

  • Hold this position for __________ seconds. Slowly lower the wrist back to the starting position in a controlled manner.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Ulnar Deviators

  • Stand with a ____________________ weight in your right / left hand or sit holding on to the rubber exercise band/tubing with your opposite arm supported.

  • Move your wrist so that your pinkie travels toward your forearm and your thumb moves away from your forearm.

  • Hold this position for __________ seconds and then slowly lower the wrist back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Radial Deviators

  • Stand with a ____________________ weight in your right / left hand or sit holding on to the rubber exercise band/tubing with your arm supported.

  • Raise your hand upward in front of you or pull up on the rubber tubing.

  • Hold this position for __________ seconds and then slowly lower the wrist back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Forearm Supinators

  • Sit with your right / left forearm supported on a table, keeping your elbow below shoulder height. Rest your hand over the edge, palm down.

  • Gently grip a hammer or a soup ladle.

  • Without moving your elbow, slowly turn your palm and hand upward to a "thumbs-up" position.

  • Hold this position for __________ seconds. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Forearm Pronators

  • Sit with your right / left forearm supported on a table, keeping your elbow below shoulder height. Rest your hand over the edge, palm up.

  • Gently grip a hammer or a soup ladle.

  • Without moving your elbow, slowly turn your palm and hand upward to a "thumbs-up" position.

  • Hold this position for __________ seconds. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.