The ulnar collateral ligament (UCL) is the main ligament on the inner side of the elbow. It holds the elbow stable against the huge “valgus” forces of throwing. Repeated throwing can stretch or tear it, which is why UCL injuries are most common in baseball pitchers, though they also occur in javelin throwers, volleyball players, gymnasts and after elbow dislocations.1 Reconstruction of the ligament is widely known as Tommy John surgery. Dr. Andrew Dold, a board-certified, fellowship-trained sports medicine surgeon in Frisco, Texas, offers the full range of UCL treatment, from rest and rehabilitation to PRP, repair and reconstruction.
- Throwers typically notice inner elbow pain and a loss of velocity or control
- Partial tears are usually treated first with rest, rehabilitation and a gradual throwing program, sometimes with PRP
- UCL repair with an internal brace can return selected athletes to throwing faster than reconstruction
- Tommy John reconstruction remains the standard for complete or worn-out ligaments, with most athletes returning to their previous level
- Overuse and high pitch counts are major risk factors
Symptoms
- Pain on the inner side of the elbow during or after throwing, especially in the late cocking and early acceleration phases
- Loss of throwing velocity, command or control1
- A sudden pop with a single throw (in an acute tear) or gradually worsening pain (with attritional damage)
- Numbness or tingling in the ring and little fingers, because the ulnar nerve lies right next to the ligament1
Diagnosis
Dr. Dold examines the elbow for tenderness over the ligament and pain or opening with stress tests that recreate the throwing load. He also checks the ulnar nerve and the flexor-pronator tendons, since golfer’s elbow can cause similar pain. MRI (sometimes with contrast) shows whether the tear is partial or complete and whether it is at the upper (humeral) or lower (ulnar) attachment. Stress ultrasound can also show how much the joint opens.
Treatment without surgery
Partial tears are usually treated first without surgery:1
- Rest from throwing, typically for several weeks
- Physical therapy focusing on the flexor-pronator muscles (which help protect the ligament), the shoulder, core and lower body
- A gradual interval throwing program once symptoms settle
- PRP injection in selected partial tears
A 2023 meta-analysis of 365 athletes treated without surgery found that about 80% returned to sport. Lower-grade tears did very well, and tears at the upper (humeral) end returned far more often than tears at the lower (ulnar) end (about 90% vs 41%). In that analysis, return-to-sport rates were not significantly different with or without PRP.2 In a small series of baseball players whose partial or complete tears had not improved with rest, 26 of 30 returned to their prior level within 6 months after ultrasound-guided needling and PRP.3 Results vary: in an older study of throwers treated with at least 3 months of rest and rehabilitation, 42% returned to their previous level.4 Dr. Dold has published a systematic review of PRP5 and will discuss whether it makes sense for your injury.
UCL repair with internal brace
For selected athletes whose ligament has pulled off one end of the bone but otherwise has good-quality tissue, Dr. Dold can repair the ligament back to bone and reinforce it with a collagen-coated suture tape (an “internal brace”). In the first large series of 111 overhead athletes, 92% of those who wanted to return to the same or higher level did so, at an average of 6.7 months.6 Whether repair or reconstruction is best is sometimes decided at the time of surgery, based on the condition of the ligament.6
UCL reconstruction (Tommy John surgery)
When the ligament is completely torn or worn out, it is reconstructed using a tendon graft, most often the palmaris longus tendon from the forearm, passed through tunnels in the bone to recreate the ligament.1 The ulnar nerve is protected and moved if needed.
- In 743 athletes followed for at least 2 years, 83% returned to their previous level of competition or higher; average time to full competition was 11.6 months.7
- Among Major League Baseball pitchers, 83% returned to pitch in the major leagues, at an average of about 20 months, and 97% returned to pitching at the major or minor league level.8
- In high school players, 74% returned to the same or higher level.9
Complications occurred in about 20% of patients in the largest series, most of them minor (16% minor, 4% major).7
Recovery
Rehabilitation starts with protecting the repair and restoring motion, then progresses to strengthening of the forearm, shoulder, core and legs, and finally a structured interval throwing program. Most athletes need about 12 to 18 months to return fully after reconstruction,1 compared with a shorter timeline after repair in suitable cases.6
Prevention for young throwers
In a study of high school players who needed UCL reconstruction, 85% reported at least one form of overuse, such as year-round throwing or high pitch counts, and many had thrown breaking pitches before age 14.9 Following pitch-count and rest guidelines, avoiding year-round throwing, and taking pain or loss of velocity seriously are the best ways to protect a young thrower’s elbow.
Why see Dr. Dold
- Board certified by the American Board of Orthopaedic Surgery, with subspecialty certification in Sports Medicine
- Sports medicine and arthroscopy fellowship at NYU Langone / Hospital for Joint Diseases; orthopedic residency at the University of Toronto
- Fellow of the American College of Surgeons (FACS), the American Academy of Orthopaedic Surgeons (FAAOS), the American Orthopaedic Association (FAOA) and the Royal College of Surgeons of Canada (FRCSC)
- Author of a SLAP repair book chapter (Springer, 2017) and research on shoulder suture anchors (KSSTA, 2013)
- Team physician and surgical consultant to Rugby Canada; has cared for professional athletes from the NFL, NBA, NHL, MLS, PGA Tour and Major League Rugby
- D Magazine Best Doctors (Collin County), 2019–2026 · Rated 4.9 on Google
Frequently asked questions
Does a UCL tear always need Tommy John surgery?
No. Many partial tears improve with rest, rehabilitation and a gradual throwing program, sometimes with PRP. In a 2023 meta-analysis, about 80% of athletes treated without surgery returned to sport.2
What is the difference between UCL repair and reconstruction?
Repair reattaches your own ligament to bone and reinforces it with suture tape; reconstruction replaces the ligament with a tendon graft. Repair is only suitable for selected tears with good tissue but can allow a faster return.6
How long is recovery after Tommy John surgery?
Most athletes need about 12 to 18 months to return fully to competitive throwing.1,7
Will I throw harder after Tommy John surgery?
Tommy John surgery is not a way to increase velocity. Its goal is to restore a stable elbow so you can return to your previous level.
Does PRP help a UCL tear?
PRP is used for some partial tears and early reports are encouraging, but a 2023 meta-analysis found no significant difference in return to sport with or without PRP.2,3
How can young pitchers prevent UCL injuries?
Avoiding overuse is key: follow pitch-count and rest guidelines, avoid year-round throwing and stop throwing when the elbow hurts.9
Research cited on this page
- Chalmers PN, Bowman E, Erickson BJ, et al. Elbow Ulnar Collateral Ligament Tears in 2023: Evaluation and Management. Instr Course Lect. 2024;73:725-736. PubMed
- Gopinatth V, Batra AK, Khan ZA, et al. Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med. 2023;51(14):3858-3869. PubMed
- Kato Y, Yamada S, Chavez J. Can platelet-rich plasma therapy save patients with ulnar collateral ligament tears from surgery?. Regen Ther. 2019;10:123-126. PubMed
- Rettig AC, Sherrill C, Snead DS, et al. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med. 2001;29(1):15-17. PubMed
- Dold AP, Zywiel MG, Taylor DW, Dwyer T, Theodoropoulos J. Platelet-rich plasma in the management of articular cartilage pathology: a systematic review. Clin J Sport Med. 2014;24(1):31-43. PubMed
- Dugas JR, Looze CA, Capogna B, et al. Ulnar Collateral Ligament Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes. Am J Sports Med. 2019;47(5):1096-1102. PubMed
- Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426-2434. PubMed
- Erickson BJ, Gupta AK, Harris JD, et al. Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. Am J Sports Med. 2014;42(3):536-543. PubMed
- Petty DH, Andrews JR, Fleisig GS, et al. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med. 2004;32(5):1158-1164. PubMed
Medically reviewed by Andrew P. Dold, MD, FAOA, FAAOS, FACS, FRCSC. This page is general information, not medical advice. Individual results vary.
