Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic.

CLINICAL SCENARIO: Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS). FOCUSED CLINICAL QUESTION: In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions? SUMMARY OF KEY FINDINGS: Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS. CLINICAL BOTTOM LINE: An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts. STRENGTH OF RECOMMENDATION: There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

Traumatic Elbow Instability: How to Fix It and When to Phone a Friend.

Traumatic elbow instability is a difficult condition to manage. Many surgeons consider the elbow a perplexing black box and evaluating damaged structures in the setting of pain and swelling a diagnostic challenge. Injury most commonly occurs from a fall onto an outstretched hand but also results from elbow dislocation, direct trauma, and sporting activities. The injury can initiate on the medial or lateral side, depending on forearm position at the time of injury, and usually follows a predictable pattern, with progressive instability caused by soft-tissue disruption and fractures of the medial or lateral column. Primary medial instability, lateral instability, and combined injury patterns have been described and discussed. Simple elbow dislocations and certain fractures can be managed nonsurgically, whereas complex patterns of instability and fracture-dislocations routinely require surgery. Stiffness and nerve injury are the most common complications and occur from both surgical and nonsurgical management. This chapter describes the diagnosis and management of traumatic elbow instability and the management of its sequela.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review.

BACKGROUND: The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE: Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS: We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS: There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS: This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Gravitational Test beyond the First Post-Newtonian Order with the Shadow of the M87 Black Hole.

The 2017 Event Horizon Telescope (EHT) observations of the central source in M87 have led to the first measurement of the size of a black-hole shadow. This observation offers a new and clean gravitational test of the black-hole metric in the strong-field regime. We show analytically that spacetimes that deviate from the Kerr metric but satisfy weak-field tests can lead to large deviations in the predicted black-hole shadows that are inconsistent with even the current EHT measurements. We use numerical calculations of regular, parametric, non-Kerr metrics to identify the common characteristic among these different parametrizations that control the predicted shadow size. We show that the shadow-size measurements place significant constraints on deviation parameters that control the second post-Newtonian and higher orders of each metric and are, therefore, inaccessible to weak-field tests. The new constraints are complementary to those imposed by observations of gravitational waves from stellar-mass sources.

Ligand Controlled Ir-Catalyzed Regiodivergent Oxyamination of Unactivated Alkenes.

An intramolecular Ir(III)-catalyzed regiodivergent oxyamination of unactivated alkenes provides valuable γ-lactams, γ-lactones and δ-lactams. The regioselectivity is controlled by the electronically tunable cyclopentadienyl Ir(III)-complexes enabling oxyamination via either 5-exo or 6-endo pathways. With respect to the mechanism, we propose a highly reactive [3.1.0] bicycle intermediate derived from Ir(V) nitrene-mediated aziridination to be a key intermediate toward the synthesis of γ-lactams.

Correlation Among Y-Balance Test-Lower Quarter Composite Scores, Hip Musculoskeletal Characteristics, and Pitching Kinematics in NCAA Division I Baseball Pitchers.

Context: Numerous studies have reported kinematic data on baseball pitchers using three-dimensional (3D) motion analysis, but no studies to date have correlated this data with clinical outcome measures. Objective: To examine the relationship among Y-Balance Test-Lower Quarter (YBT-LQ) composite scores, musculoskeletal characteristics of the hip, and pitching kinematics in National Collegiate Athletic Association (NCAA) Division I baseball pitchers. Design: Cross-sectional. Setting: 3D motion analysis laboratory. Participants: Nineteen healthy male college baseball pitchers. Main Outcome Measures: Internal and external hip passive range of motion, hip abduction strength, YBT-LQ composite scores, and kinematic variables of the pitching motion. Results: Stride length demonstrated a moderate positive correlation with dominant limb YBT-LQ composite score (r = .524, P = .02) and nondominant limb YBT-LQ composite score (r = .550, P = .01), and a weak positive correlation with normalized time to maximal humerus velocity (r = .458, P = .04). Stride length had a moderate negative correlation with normalized time to maximal thorax velocity (r = -.522, P = .02) and dominant hip total rotational motion (TRM; r = -.660, P = .002), and had a strong negative correlation with normalized time from stride foot contact to maximal knee flexion (r = -.722, P < .001). Dominant limb YBT-LQ composite score had a weak negative correlation with hip abduction strength difference (r = -.459, P = .04) and normalized time to maximal thorax velocity (r = -.468, P = .04). Nondominant limb YBT-LQ composite score demonstrated a weak negative correlation with normalized time to maximal thorax velocity (r = -.450, P = .05) and had a moderate negative correlation with dominant hip TRM (r = -.668, P = .001). There were no other significant relationships between the remaining variables. Conclusions: YBT-LQ is a clinical measure that can be used to correlate with hip musculoskeletal characteristics and pitching kinematics in NCAA Division I pitchers.

Regiodivergent Iridium(III)-Catalyzed Diamination of Alkenyl Amides with Secondary Amines: Complementary Access to γ- or δ-Lactams.

Alkenyl N-pivaloylhydroxamates undergo an Ir(III)-catalyzed diamination of the alkene with simple exogenous secondary amines under extraordinarily mild reaction conditions. The regioselectivity of the diamination is controlled by the solvent and the electronics of the cyclopentadienyl (Cpx) ligand on Ir. On the basis of a set of mechanistic experiments, we propose that the relative rates of Ir(V)-nitrenoid formation versus attack on the amido-Ir-coordinated alkene by the exogenous amine determine the outcome of the reaction.

The Clinical Impact of Bicipital Tunnel Decompression During Long Head of the Biceps Tendon Surgery: A Systematic Review and Meta-analysis.

PURPOSE: (1) To identify existing outcomes studies and (2) to use meta-analysis techniques to summarize pooled clinical outcomes for surgical techniques that decompress the bicipital tunnel and those that do not, to identify important areas for future clinical investigation. METHODS: A systematic review of the PubMed database was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Patients were categorized into 2 groups for analysis. Group 1, the "tunnel decompressed" group, included open subpectoral tenodesis, long head of the biceps tendon transfer procedures, and proximal tenodesis techniques that explicitly released the bicipital sheath. Group 2, the "tunnel not decompressed" group, included proximal tenodesis techniques and tenotomy. Validated clinical outcome measures (Constant; University of California, Los Angeles; Simple Shoulder Test; visual analog scale for pain; and American Shoulder and Elbow Surgeons) and revision rates were summarized using inverse-variance weighting in a random-effects model. Because the constituent studies were largely single-cohort observational studies, direct between-group statistical comparisons could not be made. RESULTS: Thirty studies (comprising 1,881 patients) met the inclusion and exclusion criteria. The Constant score was the most commonly reported outcome measure (16 cohorts, 961 patients) and was seemingly higher in group 1 (88.3 v 81.7). Revision rates; University of California, Los Angeles scores; Simple Shoulder Test scores; visual analog scale scores for pain; and American Shoulder and Elbow Surgeons scores appeared to be similar between groups. The mean patient age was 50.7 ± 5.7 years for group 1 and 58.9 ± 6.3 years for group 2. The Egger intercept method showed an intercept of -13.29 (P < .001) for the Constant score, indicating a high likelihood of publication bias in the included studies. CONCLUSIONS: Bicipital tunnel-decompressing techniques showed apparently higher Constant scores compared with non-decompressing techniques but may have been affected by differences in mean patient age between groups. Existing literature consists of largely single-cohort retrospective observational Level IV studies, which are likely influenced by significant publication bias. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

An affinity reagent for the recognition of pyrophosphorylated peptides.

A resin-bound dinuclear zinc(II) complex for the selective capture of pyrophosphopeptides is reported. The metal complex binds diphosphate esters over other anionic groups, such as monophosphate esters, sulfate esters, and carboxylic acids, with high specificity. Immobilization of the compound provided a reagent capable of binding and retaining nanomolar quantities of pyrophosphopeptide in the presence of cell lysate. The high affinity and specificity of the reagent makes it an attractive tool for the study of in vivo pyrophosphorylation.

Chemical pyrophosphorylation of functionally diverse peptides.

A highly selective and convenient method for the synthesis of pyrophosphopeptides in solution is reported. The remarkable compatibility with functional groups (alcohol, thiol, amine, carboxylic acid) in the peptide substrates suggests that the intrinsic nucleophilicity of the phosphoserine residue is much higher than previously appreciated. Because the methodology operates in polar solvents, including water, a broad range of pyrophosphopeptides can be accessed. We envision these peptides will find widespread applications in the development of mass spectrometry and antibody-based detection methods for pyrophosphoproteins.

New family of tilings of three-dimensional Euclidean space by tetrahedra and octahedra.

It is well known that two regular tetrahedra can be combined with a single regular octahedron to tile (complete fill) three-dimensional Euclidean space . This structure was called the "octet truss" by Buckminster Fuller. It was believed that such a tiling, which is the Delaunay tessellation of the face-centered cubic (fcc) lattice, and its closely related stacking variants, are the only tessellations of that involve two different regular polyhedra. Here we identify and analyze a unique family comprised of a noncountably infinite number of periodic tilings of whose smallest repeat tiling unit consists of one regular octahedron and six smaller regular tetrahedra. We first derive an extreme member of this unique tiling family by showing that the "holes" in the optimal lattice packing of octahedra, obtained by Minkowski over a century ago, are congruent tetrahedra. This tiling has 694 distinct concave (i.e., nonconvex) repeat units, 24 of which possess central symmetry, and hence is distinctly different and combinatorically richer than the fcc tetrahedra-octahedra tiling, which only has two distinct tiling units. Then we construct a one-parameter family of octahedron packings that continuously spans from the fcc to the optimal lattice packing of octahedra. We show that the "holes" in these packings, except for the two extreme cases, are tetrahedra of two sizes, leading to a family of periodic tilings with units composed four small tetrahedra and two large tetrahedra that contact an octahedron. These tilings generally possess 2,068 distinct concave tiling units, 62 of which are centrally symmetric.

The Role of Humeral Torsion on Glenohumeral Rotation in Injured Baseball Players.

Background: Differences in rotational range of motion (ROM) compared to humeral retrotorsion (HRT)-corrected rotational ROM exist in healthy baseball athletes, but it is unclear whether these differences exist in a pathological population. Purpose/Hypothesis: The purpose of this study was to determine if there are disparities between objectively measured differences in ROM and HRT-corrected deficits in injured baseball players. It was hypothesized that disparities would exist between (1) the side-to-side difference in glenohumeral external rotation (GER) and the HRT-corrected glenohumeral external rotation deficit (GERD) and (2) the side-to-side difference in glenohumeral internal rotation (GIR) and the HRT-corrected glenohumeral internal rotation deficit (GIRD). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data from 172 baseball players with shoulder or elbow injuries (45 shoulder, 127 elbow) were reviewed in July 2023. GER and GIR were measured on the injured and noninjured sides of all players, and diagnostic ultrasound was used to measure HRT. Dependent t tests were run to compare the side-to side differences in GER and GIR with the HRT-corrected GERD and GIRD, respectively. Results: In the players with a shoulder injury, there was a significant disparity between the side-to-side difference in GER and the HRT-corrected GERD (2°± 14° vs -13°± 15°, respectively) and between the side-to-side difference in GIR and the HRT-corrected GIRD (-14°± 8° vs 2°± 9°, respectively) (P < .001 for both). Similarly, players with an elbow injury had significant disparities between the side-to-side difference in GER and the HRT-corrected GERD (6°± 9° vs -10°± 9°, respectively) and between the side-to-side difference in GIR and the HRT-corrected GIRD (-12°± 8° vs 4°± 10°, respectively) (P < .001 for both). Conclusion: The results supported our hypothesis that there were disparities between objectively measured differences in GER and GIR compared with the HRT-corrected GERD and GIRD in injured baseball players. Consideration must be given to osseous adaptations that occur at the glenohumeral joint when evaluating and treating this population.

Supporting self-management for patients with Interstitial Lung Diseases: Utility and acceptability of digital devices.

INTRODUCTION: Patients diagnosed with Interstitial Lung Diseases (ILD) use devices to self-monitor their health and well-being. Little is known about the range of devices, selection, frequency and terms of use and overall utility. We sought to quantify patients' usage and experiences with home digital devices, and further evaluate their perceived utility and barriers to adaptation. METHODS: A team of expert clinicians and patient partners interested in self-management approaches designed a 48-question cross-sectional electronic survey; specifically targeted at individuals diagnosed with ILD. The survey was critically appraised by the interdisciplinary self-management group at Royal Devon University Hospitals NHS Foundation Trust during a 6-month validation process. The survey was open for participation between September 2021 and December 2022, and responses were collected anonymously. Data were analysed descriptively for quantitative aspects and through thematic analysis for qualitative input. RESULTS: 104 patients accessed the survey and 89/104 (86%) reported a diagnosis of lung fibrosis, including 46/89 (52%) idiopathic pulmonary fibrosis (IPF) with 57/89 (64%) of participants diagnosed >3 years and 59/89 (66%) female. 52/65(80%) were in the UK; 33/65 (51%) reported severe breathlessness medical research council MRC grade 3-4 and 32/65 (49%) disclosed co-morbid arthritis or joint problems. Of these, 18/83 (22%) used a hand- held spirometer, with only 6/17 (35%) advised on how to interpret the readings. Pulse oximetry devices were the most frequently used device by 35/71 (49%) and 20/64 (31%) measured their saturations more than once daily. 29/63 (46%) of respondents reported home-monitoring brought reassurance; of these, for 25/63 (40%) a feeling of control. 10/57 (18%) felt it had a negative effect, citing fluctuating readings as causing stress and 'paranoia'. The most likely help-seeking triggers were worsening breathlessness 53/65 (82%) and low oxygen saturation 43/65 (66%). Nurse specialists were the most frequent source of help 24/63 (38%). Conclusion: Patients can learn appropriate technical skills, yet perceptions of home-monitoring are variable; targeted assessment and tailored support is likely to be beneficial.

A narrative review of little league shoulder: proximal humeral physis widening is only one piece of the puzzle, it is time to consider posterior glenoid dysplasia.

Baseball athletes across all levels of play are at an increased risk for upper extremity injury due to the supraphysiologic demands on the shoulder and elbow during overhead throwing. Little league baseball players present with a unique subset of injuries that can affect the growth plate, commonly at the shoulder or the elbow. Ascertaining a diagnosis and plan of care for little league shoulder (LLS) historically focuses on the proximal humeral physis in skeletally immature throwing athletes presenting with shoulder pain. However, while not a current standard of care, posterior glenoid dysplasia is often present in youth baseball athletes presenting with LLS, warranting a shift in the way clinicians evaluate for and treat the youth baseball athlete's pathologic shoulder. Therefore, purpose of this narrative review is 2-fold: first, to describe the current standard of care as it relates to a diagnosis of LLS, and second, to critically describe a comprehensive evaluation process for youth throwing athletes with shoulder pain that includes screening for evidence of posterior glenoid dysplasia. This paper summarizes the current state of the available evidence for anatomic considerations of LLS in the baseball athletes throwing shoulder. Additionally, we provide a framework for clinical evaluation using a multidisciplinary approach to evaluate the entire kinetic chain of the youth baseball athlete presenting with LLS and posterior glenoid dysplasia. A case study is presented to describe common presentations, clinical and objective examinations, and a plan of care from time of evaluation to return to throwing.

Research priorities for progressive pulmonary fibrosis in the UK.

INTRODUCTION: Health research bodies recommend patient involvement and engagement in research and healthcare planning, although their implementation is not yet widespread. This deficiency extends to progressive pulmonary fibrosis (PPF), where crucial aspects remain unknown, including causal mechanisms, curative treatments and optimal symptom management. This study addresses these gaps by seeking stakeholders' perspectives to guide research and treatment directions. METHOD: A priority-setting partnership was established to explore stakeholders' priorities in the diagnosis, treatment, management and care of PPF, including idiopathic pulmonary fibrosis which is the archetypal PPF. Stakeholders included people living with PPF, their carers, relatives and healthcare professionals involved in their management. RESULTS: Through an online open-ended survey, 2542 responses were collected from 638 stakeholders. Thematic analysis identified 48 specific research questions, which were then cross-referenced with academic literature to pinpoint research gaps. Following the evidence check, 44 unanswered questions were shortlisted by 834 stakeholders in a second online survey. Ultimately, a top 10 priority list was established through consensus.The prioritised research questions include (1) improved diagnosis accuracy and timing, (2) development of new treatments, (3) enhanced accuracy in primary care, (4) optimal timing for drug and non-drug interventions, (5) effective cough treatment, (6) early intervention for PPF, (7) improved survival rates, (8) symptom reduction, (9) impact of interventions on life expectancy and (10) new treatments with reduced side effects. CONCLUSION: Stakeholders' priorities can be summarised into five areas: early diagnosis, drug and non-drug treatments, survival and symptom management. Ideally, these topics should guide funding bodies and health policies.

Dynamic Posterior Instability Test: A New Test for Posterior Glenohumeral Instability.

Background: Recurrent posterior shoulder instability has become an increasingly recognized cause of shoulder disability, especially among athletes. The presentation can be vague and therefore its clinical diagnosis is often overlooked. Few diagnostic tests exist and these tests are difficult to perform in an anxious and apprehensive patient. Many also lack high specificity and do not effectively distinguish posterior labral tears from other shoulder pathologies. As a result, the authors worked to develop a new test, the dynamic posterior instability test (DPIT). The purpose of this study was to describe the DPIT as well as a modified DPIT test and to evaluate the accuracy of these tests in detecting posterior labral pathology. It was hypothesized that the dynamic posterior instability test (DPIT) would improve accuracy in the evaluation of posterior labral tears. Methods: For a 9-month period, the DPIT and modified DPIT tests were performed on all patients evaluated for posterior instability of the shoulder. The records of all patients who had undergone a posterior labral repair (type VIII SLAP and posterior labral tears) were reviewed. The results of the DPIT and modified DPIT tests were compared to intra-operative findings. Anterior glenohumeral instability patients were also evaluated with these tests to serve as a control. Results: Fifty-one patients had a positive and 3 patients had a negative DPIT test. Of the anterior instability patients, there was 1 positive and 19 negative test results. The sensitivity of the DPIT test was 94.4%, specificity 95%, the positive predictive value 0.98, and the negative predictive value 0.86. The results of the modified DPIT were the same as the DPIT test. Conclusions: The DPIT and modified DPIT tests provide a valuable new tool when combined with history and other physical examination findings improve the accuracy of diagnosis of posterior shoulder instability.

Differences in Shoulder Internal Rotation Strength Between Baseball Players With Ulnar Collateral Ligament Reconstruction and Healthy Controls.

BACKGROUND: Studies have indicated decreased shoulder internal rotation (IR) and external rotation (ER) strength in the throwing limb of baseball players after ulnar collateral ligament injury. There is limited evidence on the recovery of shoulder rotation strength after primary ulnar collateral ligament reconstruction (UCLR). HYPOTHESIS: At the time of return to throwing, baseball players who underwent UCLR would demonstrate decreased IR and ER shoulder strength in the throwing arm as compared with healthy baseball players. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Male competitive high school and collegiate baseball athletes participated in this study. Athletes who underwent UCLR were compared with healthy controls who were matched by age, height, weight, and position. Bilateral isometric shoulder ER and IR strength was measured using a handheld dynamometer for all participants at the time of initial evaluation (UCLR group) and throughout the course of a season (healthy group). Independent t tests were run to calculate mean differences in ER and IR shoulder strength between the groups, with significance set at P < .05. RESULTS: A total of 86 baseball athletes participated in this study (43 UCLR group, 43 healthy group). At the time of return to throwing (mean ± SD, 194 ± 30 days postoperatively), the 2 groups demonstrated no significant differences in nonthrowing arm ER or IR strength (P = .143 and .994, respectively). No significant difference was found between groups for throwing arm ER strength (P = .921); however, the UCLR group demonstrated significantly less throwing arm IR strength than the healthy group (144.2 ± 27.8 vs 157.6 ± 27.1 N; P = .023). CONCLUSION: The results of this study demonstrate that throwing arm rotator cuff strength may not fully recover before the initiation of a return-to-throwing program after UCLR. These data provide a potential framework for clinicians to assist in the management and exercise prescription of the baseball athlete after UCLR and before medical release and the initiation of a return-to-throwing program.

Hypertrophy of the sublime tubercle in elbow ulnar collateral ligament injuries: a case series of baseball pitchers undergoing ulnar collateral ligament reconstruction with short-term follow-up.

Background: The ulnar collateral ligament (UCL) of the elbow is subject to repetitive stress in overhead throwing athletes. This can lead to morphologic changes at the bony attachments of the UCL and hypertrophy of the sublime tubercle. The purpose of this case series is to describe the surgical details and clinical outcomes of a series of competitive baseball pitchers with hypertrophic sublime tubercles who underwent UCL reconstruction (UCLR). Methods: All baseball pitchers who were treated for UCL injuries with significant hypertrophy of the sublime tubercle on preoperative imaging were included in the series. Clinical history, preoperative imaging, intraoperative findings during UCLR, and postoperative outcomes measured with the Conway scale were described. Results: Ten players (average age of 22.9 years [range 13-39]) were included (average follow-up 20.4 months [range 3-38 months]). Five patients also had symptoms of ulnar nerve compression, with 4 requiring transposition at the time of ULCR and 1 at 3 months postoperatively. Bony hypertrophy of the sublime tubercle was confirmed intraoperatively in all cases and excised before UCLR with the docking technique. Of the 7 patients with at least 12-month follow-up postoperatively, 6 had excellent outcomes, and 1 had a fair outcome. Conclusion: Although UCLR in the setting of hypertrophic sublime tubercle can be more complex than typical UCLR, excellent outcomes are achievable with preoperative recognition and surgical planning.

Elbow arthroscopy: valgus extension overload.

Valgus torque combined with deceleration produces high compression and shear forces acting on the posteromedial olecranon and the posteromedial trochlea. This valgus extension overload process may cause posteromedial trochlea chondromalacia, chondral flap formation, osteochondrosis, subchondral erosion, a subchondral insufficiency fracture, and marginal exostosis formation. Olecranon pathologies include proximal stress reaction, a posteromedial tip stress fracture, a transverse proximal process stress fracture, exostosis formation, exostosis fragmentation, and intra-articular loose bodies. Symptoms include posteromedial elbow pain during the deceleration phase of the throwing motion. The extension impingement test reproduces posterior or posteromedial pain similar to that experienced while throwing. Special radiographic techniques and CT scans can show loose bodies and osteophyte fragmentation. Surgical treatment is indicated when symptoms persist despite nonsurgical management. Based on clinical and basic science research, all patients with valgus extension overload should be comprehensively evaluated for medial ulnar collateral ligament insufficiency. Surgical treatment is limited to the resection of osteophytes only; normal olecranon should not be resected.