Your Elbow Hurts When You Pitch. Your MRI Is Normal. You've Been Told Nothing Is Wrong.
There Is Another Explanation.
Valgus extension overload — VEO — is one of the most commonly missed diagnoses in the throwing athlete's elbow. It does not reliably show up on X-ray. It does not reliably show up on MRI. It does not reliably show up on CT. And if your doctor, therapist, or trainer does not know to specifically look for it and test for it, it will be missed entirely.
Dr. Raffy Mirzayan is a double-board certified orthopedic sports medicine surgeon who has spent 25 years caring for baseball players at every level — from youth athletes to professional pitchers. He has examined hundreds, if not thousands, of baseball player elbows. He knows this diagnosis. He knows how to find it. And he knows how to treat it — including how to distinguish it from a UCL tear, how to manage both conditions when they occur together, and how to perform surgery when it is needed without creating new problems in the process.
If you are a pitcher with elbow pain, a normal MRI, and no answers — call (310) 746-5918. This may be exactly what you have.
What Is Valgus Extension Overload?
Every time a pitcher throws, enormous forces are generated at the elbow. The elbow snaps into extension at ball release, and at the same moment, a valgus force — a force pushing the forearm away from the body — is applied to the joint. These two forces combine to drive a bony prominence at the back of the elbow called the olecranon into the back of the humerus with tremendous speed and force.
Do this thousands of times across a career — or hundreds of times across a single season — and the result is predictable: inflammation, bone spur formation at the back of the elbow, cartilage damage, and pain that occurs specifically at ball release, at the very end of the throwing motion.
That is valgus extension overload. It is not a vague overuse injury. It is a specific, mechanistically understood condition with a specific pain pattern, a specific physical examination finding, and a specific treatment pathway.
The reason it gets missed is straightforward: imaging is often normal, particularly early in the disease course. A small developing bone spur at the back of the elbow may not be visible on X-ray. An MRI ordered to evaluate elbow pain in a pitcher will frequently return as unremarkable. And if the examining physician is not specifically testing for VEO — with their hands, with a targeted physical examination — the diagnosis will not be made.
The Examination Is Everything
This is where experience matters in a way that cannot be replicated by a radiology report.
Dr. Mirzayan performs a dynamic VEO stress test — a specific physical examination maneuver that reproduces the forces on the back of the elbow at ball release. When this test is positive, it reproduces the pitcher's exact pain, in the exact location, at the exact point in the range of motion where they experience it during throwing.
One of the most common things Dr. Mirzayan hears from pitchers in his office is: "You're the first person who has been able to exactly reproduce my pain with that test."
That is not a coincidence. It is the result of knowing what to look for, knowing how to look for it, and having examined enough throwing elbows to recognize the pattern immediately.
VEO and UCL Tears: Two Conditions, One Elbow
This is where the diagnosis becomes genuinely complex — and where the stakes of getting it wrong are highest.
Valgus extension overload rarely occurs in isolation in a competitive pitcher. The same valgus forces that drive the olecranon into the back of the humerus also stress the UCL — the ulnar collateral ligament, the Tommy John ligament — on the inside of the elbow. As a result, VEO and UCL injury frequently coexist in the same elbow, at the same time, in the same athlete.
The critical question — and the one that determines the entire treatment plan — is: which problem is primarily responsible for the pain? Or are both contributing equally?
Getting this wrong has consequences. If only the UCL is treated and the VEO is ignored, the pitcher may continue to have pain at the back of the elbow after Tommy John surgery requiring a second operation and unnecessarily extending the rehabilitation program. If only the VEO is treated arthroscopically and an underlying UCL tear is missed, the UCL may progress to complete rupture during the return to throwing.
The way to separate these two diagnoses is through a careful history and a targeted physical examination — not imaging alone.
UCL injuries typically cause pain on the inside (medial) aspect of the elbow during the acceleration phase of throwing — when the elbow is at approximately 90 degrees and the arm is coming forward. The pain is over the UCL itself, on the medial side of the joint. The dynamic valgus stress test — which applies a valgus force to the elbow at 70 to 90 degrees of flexion — reproduces UCL pain.
VEO causes pain at a different moment: at the very end of the throwing cycle, at ball release, when the elbow snaps into full extension and the olecranon impacts the posterior humerus. The pain is at the back of the elbow, not the inside. The dynamic VEO stress test — not the valgus stress test — reproduces this pain.
An experienced examiner can separate these two pain patterns in a single clinical visit. An examiner who is unfamiliar with VEO may attribute all elbow pain in a pitcher to the UCL — and send a patient to Tommy John surgery who has VEO, or to VEO surgery who actually needs Tommy John.
Dr. Mirzayan performs both examinations at every visit with a throwing athlete. He does not assume. He tests.
Treatment
Non-Operative Treatment — The First Step
For most pitchers diagnosed with VEO — particularly those caught early in the course of the condition — non-operative treatment is the appropriate first step, and many athletes can return to competition within the same season.
Non-operative management includes a period of rest from throwing, a structured physical therapy program focused on elbow flexibility and posterior capsule stretching, shoulder and rotator cuff strengthening to reduce stress on the elbow, throwing mechanics evaluation and correction, and a carefully supervised interval throwing program before return to competition.
Timing matters. A pitcher who is diagnosed with VEO early in the season, before significant bone spur formation has occurred, has a much better chance of returning in-season with conservative management than one who has been throwing through pain for months while the diagnosis was being missed.
Surgical Treatment — When Non-Operative Management Fails
When conservative treatment does not provide adequate relief, or when bone spur formation is significant enough that non-operative management is unlikely to succeed, arthroscopic surgery is indicated.
The procedure involves removing the bone spur at the back of the elbow — the osteophyte that is impacting the posterior humerus at ball release — along with any loose bodies or inflamed tissue in the posterior compartment of the joint.
This is where surgical experience is not optional — it is essential.
The amount of bone removed matters enormously. The olecranon tip is not just a site of impingement — it also plays a structural role in stabilizing the elbow against valgus stress. If too much bone is removed by an inexperienced surgeon, the result is reduced valgus stability of the elbow, increased stress on the UCL, and the potential for a UCL tear that did not exist before surgery — or acceleration of a partial UCL tear that was being managed conservatively. The surgeon who removes too much bone in the posterior compartment of a pitcher's elbow may inadvertently create the need for Tommy John surgery.
Dr. Mirzayan's 25 years of experience operating on pitchers' elbows — including more than 1,000 elbow arthroscopies — informs a precise, conservative approach to posterior elbow debridement. The goal is to remove exactly what needs to be removed, and nothing more.
In pitchers who have both VEO and a UCL tear requiring surgery, both conditions can be addressed — at the same time — with a single rehab program. This decision requires careful judgment and a surgeon who is equally comfortable in both the posterior and medial compartments of the elbow.
Coming from Las Vegas, Phoenix, or Out of State?
Valgus extension overload is a diagnosis that requires an experienced examiner. It is not found on a radiology report. It is found by a physician who has spent decades with their hands on throwing athletes' elbows — and who knows exactly what they are feeling for.
If your son is a pitcher who has been told his elbow is normal but continues to have pain, or if you are an overhead athlete who has been playing through elbow symptoms without a clear diagnosis, traveling to Los Angeles to see Dr. Mirzayan may be the most efficient path to an answer — and to getting back on the mound.
Virtual consultations are available. For out-of-state patients, Dr. Mirzayan can review your imaging, discuss your history in detail, and determine whether an in-person evaluation in Los Angeles is the appropriate next step. Many patients with commercial insurance — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, and self-funded employer plans — have strong out-of-network benefits with little out of pocket expense or equivalent to in-network physicians. Dr. Mirzayan's office will verify your coverage before your visit and guide you through this process.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is valgus extension overload and why does it happen in pitchers?
Valgus extension overload is a condition that develops in overhead throwing athletes when the repetitive stress of pitching drives a bony prominence at the back of the elbow — the olecranon — into the humerus at ball release. Over time this causes inflammation, bone spur formation, and cartilage damage at the back of the elbow. It is a mechanical consequence of the extreme forces generated during high-velocity throwing, and it is one of the most common — and most commonly missed — elbow conditions in competitive baseball players.
Why is VEO so often missed?
Because imaging is frequently normal. X-rays, MRI, and CT scans may all appear unremarkable, particularly early in the course of the condition. The diagnosis requires a physician who knows to specifically examine for VEO — using a dynamic physical examination test that reproduces the forces at the back of the elbow at ball release. If the examining physician is not familiar with this condition and this test, the diagnosis will not be made. Dr. Mirzayan has examined hundreds to thousands of baseball player elbows over 25 years and makes this diagnosis routinely — often in patients who have been told their imaging is normal and nothing is wrong.
How is VEO different from a UCL tear?
Both conditions are common in pitchers and they frequently occur together — but they cause pain at different moments in the throwing cycle and in different locations. UCL pain occurs on the inside of the elbow during acceleration, when the arm is coming forward and the elbow is near 90 degrees. VEO pain occurs at the back of the elbow at ball release, at the very end of the throwing motion. Each condition has its own specific physical examination test. Separating the two requires an experienced examiner with hands-on knowledge of both conditions.
Can a pitcher have both VEO and a UCL tear at the same time?
Yes — and this is common. The same forces that cause VEO also stress the UCL. When both conditions are present, both must be identified and addressed. Treating only the UCL and ignoring VEO can leave a pitcher with continued posterior elbow pain after Tommy John surgery. Treating only the VEO in a pitcher who also needs Tommy John surgery may result in UCL rupture during the return to throwing. Dr. Mirzayan evaluates both the medial and posterior compartments of the elbow in every throwing athlete he examines.
What happens if too much bone is removed during VEO surgery?
The olecranon tip plays a structural role in stabilizing the elbow against valgus stress. If an inexperienced surgeon removes too much bone during posterior elbow debridement, the result can be reduced valgus stability, increased stress on the UCL, and a new or worsened UCL injury that did not exist before surgery. This is one of the most important reasons to seek a surgeon with deep experience in the throwing athlete's elbow. Dr. Mirzayan has performed more than 1,000 elbow arthroscopies and approaches posterior debridement in pitchers with a precise, conservative technique designed to protect the UCL.
Can VEO be treated without surgery?
Yes — and non-operative treatment is always the first step. Many pitchers diagnosed with VEO early, before significant bone spur formation, can return to competition within the same season with rest, physical therapy, and a supervised return-to-throwing program. Surgery is reserved for cases where conservative management has failed or where the bone spur is large enough that non-operative treatment is unlikely to succeed.
How long is recovery after VEO surgery?
Recovery after arthroscopic posterior elbow debridement for VEO is typically 3 to 6 months to return to competitive pitching. Dr. Mirzayan will give you a personalized return-to-sport timeline based on your specific case.
Do you see players from outside Los Angeles?
Yes. Dr. Mirzayan regularly evaluates and treats overhead athletes from Las Vegas, Phoenix, Scottsdale, and across the country. Virtual consultations are available for out-of-state patients. For a young pitcher with unexplained elbow pain and normal imaging, a consultation with Dr. Mirzayan — in person or by video — is often the fastest path to an accurate diagnosis. Call (310) 746-5918.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience caring for overhead athletes and baseball players at every level of competition. He has performed more than 1,000 elbow arthroscopies and 350 Tommy John surgeries, and has examined hundreds to thousands of baseball player elbows over the course of his career. Valgus extension overload is a condition he diagnoses and treats routinely — including in patients who have seen multiple physicians and been told their imaging is normal. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
