Tommy John Surgery: Ulnar Collateral Ligament Reconstruction Explained

A comprehensive guide to Tommy John surgery, why it’s needed, how it’s performed, and what to expect before and after the procedure.

By Medha deb

Created on Oct 3, 2025

A comprehensive guide to Tommy John surgery, why it’s needed, how it’s performed, and what to expect before and after the procedure.

Tommy John Surgery: Ulnar Collateral Ligament Reconstruction

Tommy John surgery, medically known as ulnar collateral ligament (UCL) reconstruction, is a specialized procedure performed to repair a crucial ligament on the inner (medial) side of the elbow. Most famously associated with baseball pitchers and overhead-throwing athletes, this surgery can restore stability to the elbow and enable athletes to return to high-level participation after otherwise career-ending injuries.

What is Tommy John Surgery?

Tommy John surgery refers to the reconstruction of the ulnar collateral ligament (UCL) in the elbow using a tendon graft, usually harvested from another part of the patient’s body or a donor. The goal is to restore the structural integrity of the elbow, allowing for overhead throwing and heavy use without pain or instability.

Named after Tommy John, the first Major League Baseball pitcher to undergo the procedure in 1974.
The UCL is critical for elbow stability, especially in throwing motions.
Most often required in athletes whose sport involves repetitive overhead activities.

Understanding the Ulnar Collateral Ligament (UCL)

The UCL is a strong band of tissue located on the inner (medial) side of the elbow. It connects the upper arm bone (humerus) to the forearm bone (ulna), functioning as the main stabilizer for the elbow against valgus stress (forces that push the forearm outward).

Anatomy Highlights

Location: Runs along the inner side of the elbow joint.
Function: Prevents the elbow from bending open under load, particularly during throwing.
Importance: Essential for athletes, especially pitchers, javelin throwers, and tennis players.

UCL Injuries: Causes and Symptoms

UCL injuries are prevalent in sports involving repetitive or forceful overhead arm motions. Over time, the ligament may stretch, fray, or rupture, often leading to significant pain and instability.

Causes of UCL Injuries

Repetitive overhead throwing (baseball, softball, javelin)
High-stress arm motions such as serving in tennis or playing volleyball
Trauma from falls or direct blows to the elbow (less common)

Symptoms of a Torn or Damaged UCL

Pain on the inner elbow, particularly during throwing
Weakness or instability in the arm
Numbness or tingling sensation in the fingers (particularly the ring and little finger)
Decreased throwing speed and performance
Difficulty with grip strength or daily activities

Diagnosis: How UCL Tears are Identified

Diagnosis typically involves a combination of medical history, physical examination, and advanced imaging. Orthopedic specialists look for specific signs and symptoms and may utilize diagnostic imaging to confirm the injury and determine its severity.

Physical assessment: checking for tenderness and instability
Imaging: MRI can visualize ligament tears and surrounding tissue damage
X-rays: may detect bone spurs or calcification due to chronic stress
Special tests: “valgus stress test” assesses stability

Non-Surgical Treatments for UCL Injuries

Most UCL injuries are initially treated with non-surgical (conservative) approaches, particularly for non-athletes or less severe injuries. Surgery is usually reserved for high-level athletes or those who fail to improve with conservative care.

Conservative Management

Rest and activity modification: avoids aggravating movements
Ice and anti-inflammatory medications: reduce pain and swelling
Physical therapy: restores strength, flexibility, and range of motion
Bracing or splinting: provides temporary elbow support
Gradual return to activity after symptoms improve

Only when symptoms persist or the patient is an elite-level athlete seeking to return to play is surgery considered.

When is Tommy John Surgery Recommended?

Surgery may be recommended in the following situations:

The patient is a professional or collegiate athlete, especially a pitcher, requiring intense overhead throwing
Pain, weakness, or instability is persistent and does not respond to rest and rehabilitation after 6-12 months
Repeated attempts at non-surgical management have failed
Significant tear, rupture, or complete loss of UCL function is diagnosed

The Tommy John Surgery Procedure: Step by Step

Tommy John surgery is a technically intricate procedure, typically taking 1–2 hours to complete. It is performed by a fellowship-trained orthopedic or sports medicine surgeon in an operating room, under regional or general anesthesia.

Graft Selection

The replacement tendon (graft) may be harvested from:

Patient’s own forearm (palmaris longus tendon, if present)
Hamstring tendon from the knee (gracilis or semitendinosus)
A donor (allograft) tendon in some cases

Core Surgical Steps

An incision (about 7–10 cm) is made on the inside of the elbow over the medial epicondyle.
The surgeon carefully moves muscles, tendons, and important nerves (such as the ulnar nerve) out of the way, protecting them during surgery.
The damaged UCL is identified; any scarred or nonfunctional tissue is removed.
Small holes are drilled in the humerus (upper arm) and ulna (forearm) bones.
The harvested tendon graft is woven through these holes, often in a figure-8 pattern, mimicking the original ligament’s course.
The graft is tightly secured with sutures or anchors, restoring structural stability.
The ulnar nerve may be repositioned (anterior transposition) to prevent future nerve irritation or “cubital tunnel syndrome.” This step reduces the risk of nerve symptoms post-surgery.
Soft tissue and skin are closed in layers; a sterile dressing and splint are applied to immobilize the elbow at 90 degrees of flexion.

Key Points Table: Tommy John Surgery Steps

Step	Details
Incision	Over medial elbow, exposing UCL, muscles, and nerves
Graft Harvest	Palmaris longus or hamstring, or cadaver tendon
Ulnar Nerve	Moved or protected to prevent nerve damage
Drilling & Graft Placement	Holes made in humerus & ulna; graft threaded
Fixation	Sutures/anchors secure graft
Closure & Immobilization	Sutures, dressing, & splint at 90° elbow flexion

Risks and Complications

As with any surgical procedure, Tommy John surgery involves certain risks, though serious complications are relatively rare in experienced hands.

Infection
Nerve injury (temporary or permanent numbness, tingling)
Failure of graft to heal or torn graft in the future
Stiffness or loss of range of motion
Persistent pain
Blood vessel injury or bleeding

Proper surgical technique and strict adherence to post-operative care significantly reduce the likelihood of complications.

Recovery Timeline: Postoperative Care and Rehabilitation

Successful recovery requires a carefully structured rehabilitation program, often supervised by a physical therapist specializing in sports rehabilitation. Returning to competitive throwing sports typically takes many months, with the highest chance of long-term elbow health and performance when guidelines are closely followed.

Immediate Postoperative Care

Elevation of the arm above the heart to minimize swelling
Sling or splint immobilizes the elbow for 1 to 3 weeks
Ice application for swelling and pain reduction
Incision care: keep clean and dry; use protective coverings when bathing

Rehabilitation Phases

Early Phase (Weeks 1–3):
- Splint or cast in place, basic hand and wrist movement allowed
- Pain and swelling management
Intermediate Phase (Weeks 3–6):
- Splint/cast removed
- Gentle range-of-motion exercises for the elbow begin
- Light stretching and muscle activation
Strengthening Phase (Weeks 7–20):
- Progressive strengthening, endurance, and flexibility work
- More advanced mobility exercises
Advanced/Sport-Specific Phase (Months 6–12):
- Intensive physical therapy
- Throwing program begins in a controlled manner
- Supervised return-to-play testing

Return to Sports

Light activities: 3–4 months post-surgery
Throwing: 4–6 months (gentle, progressive)
Full return to competition: Often 9–12 months or more

Results: Success Rates and Athlete Outcomes

For well-selected candidates, especially committed athletes, Tommy John surgery boasts high success rates:

Over 80% of athletes return to their previous level of performance or higher
Pitchers and overhead-throwing athletes resume full competition within one year, in most cases
Improved pain, stability, and functional ability are common

The outcome depends on surgical expertise, diligent rehabilitation, and adherence to recovery timelines.

Prevention of UCL Injuries

Although some risk factors (such as anatomy or genetics) cannot be controlled, there are effective ways to lower the risk of UCL injuries, especially for overhead-throwing athletes:

Limit repetitive throwing; follow pitch count recommendations
Ensure adequate rest and recovery between pitching sessions
Emphasize proper technique and mechanics
Maintain flexibility and strength throughout the arm, shoulder, and core
Avoid throwing when in pain; report symptoms early

Frequently Asked Questions (FAQs)

What is the success rate of Tommy John surgery?

For professional and amateur athletes, success rates exceed 80%, with most returning to their previous level of competition within a year if rehabilitation is followed closely.

Will my elbow be as strong as before?

Most patients experience a return of strength and function comparable to their pre-injury level, though individual results vary. Rarely, minor differences in grip strength or throwing speed may persist.

Can I return to throwing and pitching after surgery?

Yes. A gradual, progressive return-to-throwing program is implemented during rehabilitation. Most athletes begin a structured throwing program at four to six months and return to full competition around nine to twelve months post-surgery.

What happens if I don’t have surgery for my UCL injury?

Non-surgical treatments may provide relief, especially in non-athletes or minor sprains. However, complete UCL tears in athletes often prevent a return to high-level overhead throwing without surgery.

Are there any long-term limitations or risks?

While most enjoy long-term positive outcomes, some may develop stiffness, nerve symptoms, or rarely need revision surgery. Ongoing conditioning and safe mechanics are advised to protect the reconstructed ligament.

Is Tommy John surgery performed only on athletes?

No, the procedure can benefit anyone with severe UCL injuries causing instability or pain that doesn’t respond to conservative care. However, most recipients are athletes involved in overhead or throwing sports.

Summary

Tommy John surgery (UCL reconstruction) is a groundbreaking advance in sports medicine, offering a second chance for athletes facing career-ending elbow injuries. By recreating a stable ligament using a healthy tendon, and following a focused rehabilitation plan, most patients regain pain-free function and performance, demonstrating the power of modern orthopedic surgery in restoring both health and dreams.

References

Author

medha deb

Medha Deb is an editor with a master's degree in Applied Linguistics from the University of Hyderabad. She believes that her qualification has helped her develop a deep understanding of language and its application in various contexts.

Read full bio of medha deb