The Centers for Advanced Orthopaedics
Maryland Orthopedic Specialists
A Division of The Centers for Advanced Orthopaedics
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Elbow

Posterior Elbow Impingement

Posterior elbow impingement is a painful syndrome affecting throwing athletes and overhead sport participants in which osteophytes or soft tissue at the posterior elbow are compressed during terminal extension, causing pain and limiting performance. When associated with the valgus mechanics of throwing, it is termed valgus extension overload (VEO) syndrome. At Maryland Orthopedic Specialists, we specialize in the diagnosis and arthroscopic management of posterior compartment pathology to return athletes to full competition.

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What is posterior elbow impingement?

During the acceleration and follow-through phases of the overhead throw, the elbow rapidly extends from approximately 100° to near full extension, simultaneously under valgus load. This repetitive combination of forced extension and valgus stress causes the posteromedial olecranon tip to impinge against the medial wall of the olecranon fossa.

During the acceleration and follow-through phases of the overhead throw, the elbow rapidly extends from approximately 100° to near full extension, simultaneously under valgus load. This repetitive combination of forced extension and valgus stress causes the posteromedial olecranon tip to impinge against the medial wall of the olecranon fossa.

Over time, this repetitive impact produces:

  • Olecranon tip osteophytes — bony spurs at the posterior olecranon tip
  • Olecranon fossa osteophytes — within the fossa itself
  • Posterior capsular thickening and fibrosis
  • Loose body formation from osteophyte fragmentation

This is the essence of valgus extension overload (VEO) syndrome: the medial laxity created by UCL attenuation amplifies the valgus-extension arc, focusing abnormal compressive forces on the posteromedial olecranon. Importantly, posterior impingement and UCL insufficiency frequently co-exist and must both be evaluated.

Non-throwing athletes (gymnasts, weightlifters, manual laborers) can also develop posterior impingement from repetitive hyperextension without a valgus component.

Treatment options

Conservative (First-Line): - Activity modification — reducing throwing volume and intensity. - Physical therapy: posterior capsular stretching, periscapular and rotator cuff strengthening, mechanics analysis. - NSAIDs and ice for symptom management. - Corticosteroid injection into the posterior compartment or olecranon fossa for acute inflammation. A structured 3–6 month non-operative trial is appropriate for athletes with mild-to-moderate symptoms. Arthroscopic osteophyte resection (Surgical): When conservative management fails, elbow arthroscopy with posterior compartment debridement and olecranon osteophyte resection is the procedure of choice: - Loose bodies are removed. - Osteophytes are excised with an arthroscopic bur. - The posterior capsule is released if there is a contracture. - Critical: The medial wall of the olecranon and its articulation with the medial trochlea must be preserved; over-resection destabilizes the elbow. - Concurrent UCL reconstruction is performed if significant medial instability is present at the same operative setting or as a planned staged procedure. Outcomes are good to excellent in the majority of cases; most athletes return to competitive throwing within 3–4 months if the UCL is intact.

Non-operative treatment

A structured 3 to 6 month conservative trial is appropriate for athletes with mild-to-moderate symptoms. Activity modification reduces throwing volume and intensity while physical therapy addresses posterior capsular tightness, periscapular and rotator cuff strength deficits, and throwing mechanics. NSAIDs and ice manage day-to-day symptoms, and a corticosteroid injection into the posterior compartment or olecranon fossa can quiet acute inflammatory flares and allow rehabilitation to progress.

Surgical Procedure

Elbow Arthroscopy

Minimally invasive joint scope to address loose bodies, osteochondritis dissecans, posterior impingement, and selected cases of refractory lateral epicondylitis through small portals at the elbow.

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Frequently Asked Questions

Will my elbow get better without surgery?
Many athletes respond well to a structured non-operative program, particularly those with early-stage impingement and no established osteophytes. However, bony osteophytes will not resolve without surgery, and continued high-velocity throwing risks loose body formation and progression.
Can I have arthroscopy and Tommy John at the same time?
In selected patients with concurrent posterior impingement and UCL insufficiency, combined procedures are performed. The surgical plan depends on the relative severity of each problem and the surgeon's assessment.
How quickly can I return to pitching after elbow arthroscopy?
For isolated posterior impingement (without UCL reconstruction), most pitchers return to competitive throwing within 3–4 months of arthroscopic debridement.
What causes posterior elbow impingement in throwers?
In overhead athletes, posterior elbow impingement typically results from the olecranon (the bony tip of the elbow) repeatedly slamming into the olecranon fossa at the back of the humerus during the acceleration and follow-through phases of throwing. Over time, this repetitive impact causes bone spurs (osteophytes) to form at the tip of the olecranon. Valgus overload — the stress placed on the inside of the elbow during throwing — worsens the impingement, which is why UCL insufficiency and posterior impingement often coexist in the same thrower. At MOS, your evaluation will assess the entire elbow to identify all contributing factors.
What does recovery from posterior elbow arthroscopy look like?
After arthroscopic surgery to remove posterior osteophytes and loose bodies, most patients have minimal discomfort and begin gentle elbow range-of-motion exercises within the first few days. Swelling and stiffness typically resolve over 4–6 weeks with physical therapy. Throwers begin an interval throwing program around 6–8 weeks post-operatively and, in straightforward cases, return to competitive pitching at approximately 3–4 months. If the UCL was also addressed at the same time, the return-to-throwing timeline follows the longer Tommy John recovery schedule, which your MOS surgeon will walk you through in detail.

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Medically reviewed by Peter G. Fitzgibbons, MD, MD
Last reviewed June 16, 2026

References

  1. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. American Journal of Sports Medicine (AJSM). 1995;23(4):407–413. https://doi.org/10.1177/036354659502300405
  2. Kooima CL, Anderson K, Craig JV, Teague DC, ElAttrache NS. Evidence of subclinical medial collateral ligament injury and posteromedial impingement in professional baseball players. American Journal of Sports Medicine (AJSM). 2004;32(7):1602–1606. https://doi.org/10.1177/0363546504264150
  3. American Academy of Orthopaedic Surgeons. Elbow Impingement — OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/valgus-extension-overload (accessed May 2026).
  4. Dodson CC, Nho SJ, Williams RJ 3rd, Altchek DW. Elbow arthroscopy. Journal of the American Academy of Orthopaedic Surgeons (JAAOS). 2008;16(10):574–585. https://doi.org/10.5435/00124635-200810000-00002